Effective for Dates of Service On or Before March 31, 2009 Only mc sup prod ost twohi Medical Supply Products: Ostomy Two-Piece High Output/Urinary Pouches 1

This section lists the billing codes, manufacturer codes and units for ostomy medical supplies. In this section, “UPN” refers to the Universal Product Number. For additional help, refer to the Medical Supplies section in this manual. HCPCS codes are for reference only.

Effective Dates All two-piece ostomy products are effective for dates of service on or after August 1, 2007 unless otherwise noted.

TWO-PIECE OSTOMY PRODUCTS HCPCS Maximum (reference Billing Acquisition Unit of Description UPN only) Code Cost (MAC) Measure TWO-PIECE HIGH OUTPUT POUCHES (Limited to no more than 90 pouches in an 81-day period without authorization.) Coloplast – JN Assura - 2-Pc. Ileo Night Pouch / 2L 0762123028827 A4413 9907LJN $5.10 each 1/2" - 2" (13-50 mm) / Red Assura - 2-Pc. Ileo Night Pouch / 2L 0762123028841 A4413 9907LJN $5.10 each 1/2" - 2 3/8" (13-60 mm) / Blue Assura - 2-Pc. High Output Pouch / 600 ml 0762123028865 A4413 9907LJN $5.10 each 1/2" - 2" (13-50 mm) / Red Assura - 2-Pc. High Output Pouch / 600 ml 0762123028889 A4413 9907LJN $5.10 each 1/2" - 2 3/8" (13-60 mm) / Blue Assura 2-pc High Output Pouch, Transparent 40 mm (Green) 0762123049372 A4413 9907LJN $5.10 each Assura 2-pc High Output Pouch, Transparent 50 mm (Red) 0762123049396 A4413 9907LJN $5.10 each Assura 2-pc High Output Pouch, Transparent 60 mm (Blue) 0762123049419 A4413 9907LJN $5.10 each

2 – Medical Supply Products: Ostomy Two-Piece High Output/Urinary Pouches June 2008 mc sup prod ost twohi Effective for Dates of Service On or Before March 31, 2009 Only 2

HCPCS Maximum (reference Billing Acquisition Unit of Description UPN only) Code Cost (MAC) Measure

Convatec – SQ SUR-FIT Natura High Output Pouch, Opaque, 30003401557 A4413 9907LSQ $5.10 each † one-sided comfort panel, with filter, 1 3/4" 2 1/4" 30003401558 A4413 9907LSQ $5.10 each † 2 3/4" 30003401559 A4413 9907LSQ $5.10 each † Hollister – HS Ni high output w/soft tap 1 3/4" (44 mm) 10610075114716 A4412 9914UHS $5.50 each Ni high output w/soft tap 2 1/4" (57 mm) 10610075114723 A4412 9914UHS $5.50 each Ni high output w/soft tap 2 3/4" (70 mm) 10610075114730 A4412 9914UHS $5.50 each Ni high output w/soft tap 4" (102 mm) 10610075114747 A4412 9914UHS $5.50 each

† Effective June 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece High Output/Urinary Pouches June 2008 Effective for Dates of Service On or Before March 31, 2009 Only mc sup prod ost twohi 3

HCPCS Maximum (reference Billing Acquisition Unit of Description UPN only) Code Cost (MAC) Measure

TWO-PIECE URINARY POUCHES (Limited to no more than 90 pouches in an 81-day period without authorization.) Coloplast – JN Assura AC URO Transp. 35 mm, Green 0762123050088 A4432 9915ZJN $3.20 each Assura AC URO Opaque 35 mm, Green 0762123050101 A4432 9915ZJN $3.20 each Assura AC URO Transp. 50 mm, Red 0762123050125 A4432 9915ZJN $3.20 each Assura AC URO Opaque 50 mm, Red 0762123050149 A4432 9915ZJN $3.20 each Assura - 2-Pc. Urostomy Pouch, Opaque Standard 375 ml 10" 0762123031544 A4433 9915ZJN $3.20 each (25 cm), matches green flange sizes Assura - 2-Pc. Urostomy Pouch, Opaque Standard 375 ml 10" 0762123031605 A4433 9915ZJN $3.20 each (25 cm), matches red flange sizes Assura - 2-Pc. Urostomy Pouch, Opaque Standard 375 ml 10" 0762123031643 A4433 9915ZJN $3.20 each (25 cm), matches blue flange sizes Assura - 2-Pc. Urostomy Pouch, Transparent Standard 375 ml 076212303157 A4433 9915ZJN $3.20 each 10" (25 cm), matches green flange sizes Assura - 2-Pc. Urostomy Pouch, Transparent Standard 375 ml 0762123031629 A4433 9915ZJN $3.20 each 10" (25 cm), matches red flange sizes Assura - 2-Pc. Urostomy Pouch, Transparent Standard 375 ml 076212303136 A4433 9915ZJN $3.20 each 10" (25 cm), matches blue flange sizes

2 – Medical Supply Products: Ostomy Two-Piece High Output/Urinary Pouches June 2008 Effective for Dates of Service On or Before March 31, 2009 Only mc sup prod ost twohi 4

HCPCS Maximum (reference Billing Acquisition Unit of Description UPN only) Code Cost (MAC) Measure

Coloplast – JN Assura - 2-Pc. Urostomy Pouch, Transparent Small 150 ml, 0726213031520 A4433 9915ZJN $3.20 each 9 1/2" (24 cm), matches green flange sizes Assura - 2-Pc. Urostomy Pouch, Transparent Small 250 ml, 0762123031582 A4433 9915ZJN $3.20 each 9 1/2" (24 cm), matches red flange sizes Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Opaque Maxi, 0762123043073 A4433 9915ZJN $3.20 each 456 ml, 10" (25 cm), matches green flange sizes Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Opaque Maxi, 0762123043097 A4433 9915ZJN $3.20 each 456 ml, 10" (25 cm), matches red flange sizes Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Opaque Maxi 0762123043110 A4433 9915ZJN $3.20 each 456 ml, 10" (25 cm), matches blue flange sizes Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Transparent 0762123043134 A4433 9915ZJN $3.20 each Maxi 456 ml, 10" (25 cm), matches green flange sizes Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Transparent 0762123043158 A4433 9915ZJN $3.20 each Maxi 456 ml, 10" (25 cm), matches red flange sizes Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Transparent 0762123043172 A4433 9915ZJN $3.20 each Maxi 456 ml, 10" (25 cm), matches blue flange sizes Assura - 2-Pc. Urostomy Micro-Pouch, Transparent, 0762123043011 A4433 9915ZJN $3.20 each matches green flange sizes Assura - 2-Pc. Urostomy Micro-Pouch, Transparent, 0762123043035 A4433 9915ZJN $3.20 each matches red flange sizes Assura - 2-Pc. Urostomy Micro-Pouch, Transparent, 0762123043059 A4433 9915ZJN $3.20 each matches blue flange sizes

2 – Medical Supply Products: Ostomy Two-Piece High Output/Urinary Pouches June 2008 Effective for Dates of Service On or Before March 31, 2009 Only mc sup prod ost twohi 5

HCPCS Maximum (reference Billing Acquisition Unit of Description UPN only) Code Cost (MAC) Measure

Coloplast – JN Assura - 2-Pc. Pediatric Urostomy Pouch, Transparent 8 1/2" 0762123031506 A4433 9915ZJN $3.20 each (21 cm), 150 ml 8 1/2" (21 cm) Coloplast - 2-Pc. Urostomy Pouch, Transparent Standard 375 0762123000595 A5073 9915ZJN $3.20 each ml, 10" (25 cm), matches green Coloplast flange Coloplast - 2-Pc. Urostomy Pouch, Transparent Standard 375 0762123000618 A5073 9915ZJN $3.20 each ml, 10" (25 cm), matches red Coloplast flange Coloplast - 2-Pc. Urostomy Pouch, Transparent Standard 375 0762123000632 A5073 9915ZJN $3.20 each ml, 10" (25 cm), matches blue Coloplast flange Coloplast - 2-Pc. Urostomy Pouch, Transparent Small 250 ml, 0762123000601 A5073 9915ZJN $3.20 each 7" (18 cm), matches green Coloplast flange Coloplast - 2-Pc. Urostomy Pouch, Transparent Small 250 ml, 0762123000625 A5073 9915ZJN $3.20 each 7" (18 cm), matches red Coloplast flange Convatec – SQ SUR-FIT Natura Urostomy Pouch with Accuseal Tap, 30003401542 A4432 9915ZSQ $3.20 each † Transparent, standard, one-sided comfort panel, 1 1/4" 1 1/2" 30003401543 A4432 9915ZSQ $3.20 each † 1 3/4" 30003401544 A4432 9915ZSQ $3.20 each † 2 1/4" 30003401545 A4432 9915ZSQ $3.20 each † 2 3/4" 30003401546 A4432 9915ZSQ $3.20 each †

† Effective June 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece High Output/Urinary Pouches June 2008 Effective for Dates of Service On or Before March 31, 2009 Only mc sup prod ost twohi 6

HCPCS Maximum (reference Billing Acquisition Unit of Description UPN only) Code Cost (MAC) Measure

Convatec – SQ

SUR-FIT Natura® Urostomy Pouch Bend, Trans. Sm w/1-sided 30003401538 A5073 9915ZSQ $3.20 each comfort panel, 1 1/4" SUR-FIT Natura® Urostomy Pouch Bend, Trans. Sm w/1-sided 30003401539 A5073 9915ZSQ $3.20 each comfort panel, 1 1/2" SUR-FIT Natura® Urostomy Pouch Bend, Trans. Sm w/1-sided 30003401540 A5073 9915ZSQ $3.20 each comfort panel, 1 3/4" SUR-FIT Natura® Urostomy Pouch Bend, Trans. Sm w/1-sided 30003401541 A5073 9915ZSQ $3.20 each comfort panel, 2 1/4" SUR-FIT Natura® Urostomy Pouch Bend, Trans. Std. 30003401533 A5073 9915ZSQ $3.20 each w/1-sided comfort panel, 1 1/4" SUR-FIT Natura® Urostomy Pouch Bend, Trans. Std. 30003401534 A5073 9915ZSQ $3.20 each w/1-sided comfort panel, 1 1/2" SUR-FIT Natura® Urostomy Pouch Bend, Trans. Std. 30003401535 A5073 9915ZSQ $3.20 each w/1-sided comfort panel, 1 3/4" SUR-FIT Natura® Urostomy Pouch Bend, Trans. Std. 30003401536 A5073 9915ZSQ $3.20 each w/1-sided comfort panel, 2 1/4" SUR-FIT Natura® Urostomy Pouch Bend, Trans. Std. 30003401537 A5073 9915ZSQ $3.20 each w/1-sided comfort panel, 2 3/4"

2 – Medical Supply Products: Ostomy Two-Piece High Output/Urinary Pouches June 2008 Effective for Dates of Service On or Before March 31, 2009 Only mc sup prod ost twohi 7

HCPCS Maximum (reference Billing Acquisition Unit of Description UPN only) Code Cost (MAC) Measure

Hollister – HS 2-pc urost pouch 1 3/4" 10610075039026 A4432 9915ZHS $3.20 each 2-pc urost pouch 2 1/4" 10610075039033 A4432 9915ZHS $3.20 each 2-pc urost pouch 2 3/4" 10610075039040 A4432 9915ZHS $3.20 each 2-pc urost pouch 1 1/2" 10610075039071 A4432 9915ZHS $3.20 each New image urost trans 1 3/4 10610075184023 A4432 9915ZHS $3.20 each New image urost trans 10610075184030 A4432 9915ZHS $3.20 each New image urost trans 2 3/4 10610075184047 A4432 9915ZHS $3.20 each New image urost beige 1 3/4 10610075184122 A4432 9915ZHS $3.20 each New image urost beige 10610075184139 A4432 9915ZHS $3.20 each New image urost beige 2 3/4 10610075184146 A4432 9915ZHS $3.20 each Ni clear uro 1 3/4" (44 mm) 10610075114013 A4432 9915ZHS $3.20 each Ni clear uro 2 1/4" (57 mm) 10610075114020 A4432 9915ZHS $3.20 each Ni uropch uclr 70 mm, 2 3/4” Flg 10610075132314 A4432 9915ZHS $3.20 each †

† Effective October 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece High Output/Urinary Pouches September 2008