Product Manual

Hollister Incorporated 1.888.740.8999
18
Medicare Utilization Chart
A4390 Ostomy pouch, drainable, with extended wear barrier
✳
attached, with built-in convexity (1 piece), each
A4391 Ostomy pouch, urinary, with extended wear barrier
✳
attached (1 piece), each
A4392 Ostomy pouch, urinary, with standard wear barrier
✳
attached, with built-in convexity (1 piece), each
A4393 Ostomy pouch, urinary, with extended wear barrier
✳
attached, with built-in convexity (1 piece), each
A4394 Ostomy deodorant, with or without lubricant, for use in
✳
ostomy pouch, liquid, per uid ounce
A4395 Ostomy deodorant for use in ostomy pouch, solid,
✳
per tablet
A4396 Ostomy belt with peristomal hernia support
✳
A4397 Irrigation supply, sleeve, each 4 ea/mo
A4398 Ostomy irrigation supply, bag, each 2 ea/6 mo
A4399 Ostomy irrigation supply, cone/catheter, with or without brush 2 ea/6 mo
A4402 Lubricant, per ounce 4 oz/mo
A4404 Ostomy ring, each 10 ea/mo
A4405 Ostomy skin barrier, non-pectin based, paste, per ounce 4 oz/mo
A4406 Ostomy skin barrier, pectin-based, paste, per ounce 4 oz/mo
A4407 Ostomy skin barrier, with ange (solid, exible, or
✳
accordion), extended wear, with built-in convexity,
4 x 4 inches or smaller, each
A4408 Ostomy skin barrier, with ange (solid, exible, or accordion),
✳
extended wear, with built-in convexity, larger than 4 x 4
inches, each
A4409 Ostomy skin barrier, with ange (solid, exible, or accordion),
✳
extended wear, without built-in convexity, 4 x 4 inches
or smaller, each
A4410 Ostomy skin barrier, with ange (solid, exible, or accordion),
✳
extended wear, without built-in convexity, larger than 4 x 4
inches, each
A4411 Ostomy skin barrier, solid 4 x 4 or equivalent, extended
wear, with built-in convexity, each
✳
A4412 Ostomy pouch, drainable, high output, for use on a
barrier with ange (2 piece system), without lter, each
✳
A4413 Ostomy pouch, drainable, high output, for use on a
✳
barrier with ange (2 piece system), with lter, each
A4414 Ostomy skin barrier, with ange (solid, exible, or 20 ea/mo
accordion), without built-in convexity, 4 x 4 inches or
smaller, each
A4415 Ostomy skin barrier, with ange (solid, exible, or 20 ea/mo
accordion), without built-in convexity, larger than
4 x 4 inches, each
A4416 Ostomy pouch, closed, with barrier attached, with lter 60 ea/mo
(1 piece), each
A4417 Ostomy pouch, closed, with barrier attached, with 60 ea/mo
built-in convexity, with lter (1 piece), each
A4418 Ostomy pouch, closed, without barrier attached, with 60 ea/mo
lter (1 piece), each
A4419 Ostomy pouch, closed, for use on barrier with 60 ea/mo
non-locking ange, with lter (2 piece), each
A4420 Ostomy pouch, closed, for use on barrier with locking 60 ea/mo
ange (2 piece), each
A4421 Ostomy supply; miscellaneous
✳
A4422 Ostomy absorbent material (sheet/pad/crystal packet)
✳
for use in ostomy pouch to thicken liquid stomal
output, each
HCPCS Long Description Quantity
✳
No established usual maximum, refer to Medicare Utilization Guidelines.