Advanced Wound Care / Wound Care Product / ALLEVYN. Advanced Wound Care / Wound Care / ALLEVYN

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1 Advanced Wound Care / Wound Care Product / ALLEVYN Product Name Model Number Description HCPCS Codes Medicare Fee Schedule ALLEVYN Ag Adhesive Silver Wound Dressing " x 3" [pad size 1 3/4" x 1 3/4"] A6212 $ $12.75** ALLEVYN Ag Adhesive Silver Wound Dressing " x 5" [pad size 3 1/2" x 3 1/2"] A6212 $ $12.75** ALLEVYN Ag Non-Adhesive Silver Wound Dressing " x 2", 10 Pcs/Pkg A6209 $ $9.85** ALLEVYN Ag Non-Adhesive Silver Wound Dressing " x 4", 10 Pcs/Pkg A6209 $ $9.85** ALLEVYN Ag Non-Adhesive Silver Wound Dressing " x 6", 10 Pcs/Pkg A6210 $ $26.14** ALLEVYN Ag Non-Adhesive Silver Wound Dressing " x 8", 10 Pcs/Pkg A6211 $ $38.52** ALLEVYN Ag Heel Silver Wound Dressing Heel, 5 Pcs/Pkg A6210 $ $26.14** ALLEVYN Ag Gentle " x 2" A6209 $ $9.85** ALLEVYN Ag Gentle " x 4" A6209 $ $9.85** ALLEVYN Ag Gentle " x 6" A6210 $ $26.14** ALLEVYN Ag Gentle " x 8" A6211 $ $38.52** ALLEVYN Ag Gentle Border " x 3" A6212 $ $12.75** ALLEVYN Ag Gentle Border " x 5" A6212 $ $12.75** ALLEVYN Gentle Border Multisite " x 4" A6212 $ $12.75** ALLEVYN Gentle Border Sacrum " x 6.75" carton of 10 A6212 $ $12.75** ALLEVYN Gentle Border Sacrum " x 9.00" carton of 10 A6212 $ $12.75** ALLEVYN Gentle Adhesive Hydrocellular Foam Dressings " x 2" A6209 $ $9.85** ALLEVYN Gentle Adhesive Hydrocellular Foam Dressings " x 4" A6209 $ $9.85** ALLEVYN Gentle Adhesive Hydrocellular Foam Dressings " x 6" A6210 $ $26.14** ALLEVYN Gentle Adhesive Hydrocellular Foam Dressings " x 8" A6211 $ $38.52** ALLEVYN Gentle Border Adhesive Hydrocellular Foam Dressin " x 3" A6212 $ $12.75** ALLEVYN Gentle Border Adhesive Hydrocellular Foam Dressin " x 5" A6212 $ $12.75** Advanced Wound Care / Wound Care / ALLEVYN Product Name Model Number Description HCPCS Code Medicare Fee Schedule ALLEVYN Adhesive " x 3" [pad size 1 3/4" x 1 3/4"] A6212 $ $12.75** ALLEVYN Adhesive " x 5" [pad size 3 1/2" x 3 1/2"] A6212 $ $12.75**

2 ALLEVYN Adhesive " x 9" [pad size 8" x 8"] A6214 $ $13.51** ALLEVYN Plus Adhesive " x 5" [pad size 3 1/2" x 3 1/2"] A6212 $ $12.75** ALLEVYN Life " x 4" 9 (10.3cm x 10.3cm) 10 Pcs/Pkg A6212 $ $12.75** ALLEVYN Life /16" x 5 1/16" (12.9cm x 12.9cm) 10 Pcs/ A6212 $ $12.75** ALLEVYN Life /16" x 6 1/16" (15.4cm x 15.4cm) 10 Pcs/ A6212 $ $12.75** Product Name Model Number Description HCPCS Code Medicare Fee Schedule ALLEVYN GB lite " x 2" A6212 $ $12.75** ALLEVYN GB lite " x 3" A6212 $ $12.75** ALLEVYN GB lite " x 4" A6212 $ $12.75** ALLEVYN GB lite /2" x 4 3/4" A6212 $ $12.75** ALLEVYN Self Adhesive-Thin " x 2 3/8" A6209 $ $9.85** ALLEVYN Self Adhesive-Thin " x 4" A6209 $ $9.85** ALLEVYN Self Adhesive-Thin " x 8" A6210 $ $26.14** ALLEVYN Compression " x 2 3/8" A6209 $ $9.85** ALLEVYN Compression " x 4" A6209 $ $9.85** ALLEVYN Compression " x 8" A6210 $ $26.14** ALLEVYN Heel Heel, 5 Pcs/Pkg A6210 $ $26.14** ALLEVYN Hydrocellular Foam Dressings " x 2", 10 Pcs/Pkg A6209 $ $9.85** ALLEVYN Hydrocellular Foam Dressings " x 4", 10 Pcs/Pkg A6209 $ $9.85** ALLEVYN Hydrocellular Foam Dressings " x 6", 10 Pcs/Pkg A6210 $ $26.14** ALLEVYN Hydrocellular Foam Dressings " x 8", 10 Pcs/Pkg A6211 $ $38.52** ALLEVYN Hydrocellular Foam Tracheostomy Dressings /2" x 3 1/2", 10 Pcs/Pkg A6209 $ $9.85**

3 No fee schedule for A9270 is available for this date of service. * Note: This code does not appear on the CMS National Fee Schedules available in DMECS. Please call your DME MAC/DMERC for pricing assistance. See the table below for DME MAC/DMERC contact information Jurisdiction A Jurisdiction B Jurisdiction C Jurisdiction D ** This is an average listing for the Medicare DME MAC/DMERC pricing Schedule. Outlier: The following states, Alaska, Hawaii and Puerto Rico report a slightly higher pricing. Please refer to DME MAC/DMERC for pricing assistance or visit A FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSIN A FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A FOAM DRESSING, WOUND FILLER, STERILE, PER GRAM Disclaimer: The information provided with this notice is general reimbursement information only. It is not legal advice, nor is it advice about how to code, complete or submit any particular claim for payment. Although we supply this information to the best of our current knowledge, it is always the provider s responsibility to determine and submit appropriate codes, charges, modifiers, and bills for services rendered. The coding and reimbursement information is subject to change without notice. Payers or their local branches may have their own coding and reimbursement requirements and policies. Before filing any claims, providers should verify current requirements and policies with the payer. Trademark of Smith & Nephew. Certain marks Reg. US Pat. & TM Off. 1/14

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