Medical Supply Products: Ostomy Two-Piece High Output/Urinary Pouches (Mc Sup Prod Ost Twohi)

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

Description / UPN / HCPCS (reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
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
1/2" - 2" (13-50 mm) / Red / 0762123028827 / A4413 / 9907LJN / $5.10 / each
Assura - 2-Pc. Ileo Night Pouch / 2L
1/2" - 2 3/8" (13-60 mm) / Blue / 0762123028841 / A4413 / 9907LJN / $5.10 / each
Assura - 2-Pc. High Output Pouch / 600 ml
1/2" - 2" (13-50 mm) / Red / 0762123028865 / A4413 / 9907LJN / $5.10 / each
Assura - 2-Pc. High Output Pouch / 600 ml
1/2" - 2 3/8" (13-60 mm) / Blue / 0762123028889 / A4413 / 9907LJN / $5.10 / each
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

Medical Supply Products: Ostomy Two-Piece High Output/Urinary Pouches 1

Convatec – SQ
SUR-FIT Natura High Output Pouch, Opaque,
one-sided comfort panel, with filter, 1 3/4" / 30003401557 / A4413 / 9907LSQ / $5.10 / each †
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

mc sup prod ost twohi

Description / UPN / HCPCS (reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
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" (25 cm), matches green flange sizes / 0762123031544 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Pouch, Opaque Standard 375 ml 10" (25 cm), matches red flange sizes / 0762123031605 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Pouch, Opaque Standard 375 ml 10" (25 cm), matches blue flange sizes / 0762123031643 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Pouch, Transparent Standard 375 ml 10" (25 cm), matches green flange sizes / 076212303157 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Pouch, Transparent Standard 375 ml 10" (25 cm), matches red flange sizes / 0762123031629 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Pouch, Transparent Standard 375 ml 10" (25 cm), matches blue flange sizes / 076212303136 / A4433 / 9915ZJN / $3.20 / each

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

mc sup prod ost twohi

Description / UPN / HCPCS (reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Coloplast – JN
Assura - 2-Pc. Urostomy Pouch, Transparent Small 150 ml,
9 1/2" (24 cm), matches green flange sizes / 0726213031520 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Pouch, Transparent Small 250 ml,
9 1/2" (24 cm), matches red flange sizes / 0762123031582 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Opaque Maxi, 456 ml, 10" (25 cm), matches green flange sizes / 0762123043073 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Opaque Maxi, 456 ml, 10" (25 cm), matches red flange sizes / 0762123043097 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Opaque Maxi 456 ml, 10" (25 cm), matches blue flange sizes / 0762123043110 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Transparent Maxi 456 ml, 10" (25 cm), matches green flange sizes / 0762123043134 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Transparent Maxi 456 ml, 10" (25 cm), matches red flange sizes / 0762123043158 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Multi-Chamber Pouch, Transparent Maxi 456 ml, 10" (25 cm), matches blue flange sizes / 0762123043172 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Micro-Pouch, Transparent,
matches green flange sizes / 0762123043011 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Micro-Pouch, Transparent,
matches red flange sizes / 0762123043035 / A4433 / 9915ZJN / $3.20 / each
Assura - 2-Pc. Urostomy Micro-Pouch, Transparent,
matches blue flange sizes / 0762123043059 / A4433 / 9915ZJN / $3.20 / each

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

mc sup prod ost twohi

Description / UPN / HCPCS (reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Coloplast – JN
Assura - 2-Pc. Pediatric Urostomy Pouch, Transparent 8 1/2" (21 cm), 150 ml 8 1/2" (21 cm) / 0762123031506 / A4433 / 9915ZJN / $3.20 / each
Coloplast - 2-Pc. Urostomy Pouch, Transparent Standard 375 ml, 10" (25 cm), matches green Coloplast flange / 0762123000595 / A5073 / 9915ZJN / $3.20 / each
Coloplast - 2-Pc. Urostomy Pouch, Transparent Standard 375 ml, 10" (25 cm), matches red Coloplast flange / 0762123000618 / A5073 / 9915ZJN / $3.20 / each
Coloplast - 2-Pc. Urostomy Pouch, Transparent Standard 375 ml, 10" (25 cm), matches blue Coloplast flange / 0762123000632 / A5073 / 9915ZJN / $3.20 / each
Coloplast - 2-Pc. Urostomy Pouch, Transparent Small 250 ml, 7" (18 cm), matches green Coloplast flange / 0762123000601 / A5073 / 9915ZJN / $3.20 / each
Coloplast - 2-Pc. Urostomy Pouch, Transparent Small 250 ml, 7" (18 cm), matches red Coloplast flange / 0762123000625 / A5073 / 9915ZJN / $3.20 / each
Convatec – SQ
SUR-FIT Natura Urostomy Pouch with Accuseal Tap, Transparent, standard, one-sided comfort panel, 1 1/4" / 30003401542 / A4432 / 9915ZSQ / $3.20 / each †
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

mc sup prod ost twohi

Description / UPN / HCPCS (reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Convatec – SQ
SUR-FIT Natura® Urostomy Pouch Bend, Trans. Sm w/1-sided comfort panel, 1 1/4" / 30003401538 / A5073 / 9915ZSQ / $3.20 / each
SUR-FIT Natura® Urostomy Pouch Bend, Trans. Sm w/1-sided comfort panel, 1 1/2" / 30003401539 / A5073 / 9915ZSQ / $3.20 / each
SUR-FIT Natura® Urostomy Pouch Bend, Trans. Sm w/1-sided comfort panel, 1 3/4" / 30003401540 / A5073 / 9915ZSQ / $3.20 / each
SUR-FIT Natura® Urostomy Pouch Bend, Trans. Sm w/1-sided comfort panel, 2 1/4" / 30003401541 / A5073 / 9915ZSQ / $3.20 / each
SUR-FIT Natura® Urostomy Pouch Bend, Trans. Std.
w/1-sided comfort panel, 1 1/4" / 30003401533 / A5073 / 9915ZSQ / $3.20 / each
SUR-FIT Natura® Urostomy Pouch Bend, Trans. Std.
w/1-sided comfort panel, 1 1/2" / 30003401534 / A5073 / 9915ZSQ / $3.20 / each
SUR-FIT Natura® Urostomy Pouch Bend, Trans. Std.
w/1-sided comfort panel, 1 3/4" / 30003401535 / A5073 / 9915ZSQ / $3.20 / each
SUR-FIT Natura® Urostomy Pouch Bend, Trans. Std.
w/1-sided comfort panel, 2 1/4" / 30003401536 / A5073 / 9915ZSQ / $3.20 / each
SUR-FIT Natura® Urostomy Pouch Bend, Trans. Std.
w/1-sided comfort panel, 2 3/4" / 30003401537 / A5073 / 9915ZSQ / $3.20 / each

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

mc sup prod ost twohi

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