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Official Description

Gauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. in., without adhesive border, each dressing
Short Descr Gauze > 48 sq in water/salne
Coverage Special coverage instructions apply
Pricing Indicator(s) 46 – Supplies And Surgical Dressings - Carrier priced (e.g., not otherwise classified, individual determination, carrier discretion, gap-filled amounts)
MPI A – Not applicable, as HCPCS priced under one methodology
MCM 2079
BETOS D1A – Medical/surgical supplies
TOS Code(s) S – Surgical dressings or other medical supplies
Added Date 1/1/1997
Status Code Bundled/Excluded Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 9 - Not Applicable
Multiple Procedures (51) 9 - Concept does not apply.
Bilateral Surgery (50) 9 - Concept does not apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 9 - Concept does not apply.
Co-Surgeons (62) 9 - Concept does not apply.
Team Surgery (66) 9 - Concept does not apply.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Items and Services Packaged into APC Rates
MUE 0
MUE 0
IOM 100-02, 15, 100
OTS Orthotic No
CCS Clinical Classification 243 - DME and supplies
A4 Dressing for four wounds
KX Requirements specified in the medical policy have been met
Date
Action
Notes
2009-01-01 Changed Code description changed
1997-01-01 Added Code added 1/1/1997
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