HCPCS Code |
Description |
Quantity |
A4217 |
Sterile water/saline, 500 mL |
* |
A4310 |
Insert tray without drainage
bag and without catheter (accessories only |
1 tray/insertion |
A4311 |
Insertion tray without drainage bag with indwelling
catheter, foley type, two-way latex with coating
(Teflon,silicone, silicone elastomer or hydrophilic, etc.) |
1 tray/insertion |
A4312 |
Insertion tray without drainage bag with indwelling
catheter, foley type, two-way all silicone |
1 tray/insertion |
A4313 |
Insertion tray without drainage bag with indwelling
catheter, foley type, three-way, for continuous
irrigation |
1 tray/insertion |
A4314 |
Insertion tray with drainage bag with indwelling
catheter, foley type, two-way latex with coating (Teflon, silicone,
silicone elastomer or hydrophilic, etc.) |
1 ea/mo |
A4315 |
Insertion tray with drainage bag with indwelling
catheter, foley type, two-way all silicone |
1 ea/mo |
A4316 |
Insertion tray with drainage bag with indwelling
catheter, foley type, three-way, for continuous irrigation |
1 ea/mo |
A4320 |
Irrigation tray with bulb or
piston syringe, any purpose |
* |
A4321 |
Therapeutic agent for urinary
catheter irrigation |
* |
A4322 |
Irrigation syringe, bulb or piston,
each |
* |
A4326 |
Male external catheter with integral
collection chamber, any type,
each |
* |
A4327 |
Female external urinary
collection device; meatal cup, each |
1 ea/week |
A4328 |
Female external urinary
collection device; pouch, each |
1 ea/day |
A4331 |
Extension drainage tubing, any type, any length,
with connector/adapter, for use with urinary leg bag or urostomy pouch, each |
* |
A4332 |
Lubricant, individual sterile
packet, each |
200 ea/mo |
A4333 |
Urinary catheter anchor device, adhesive skin
attachment, each |
3 ea/wk |
A4335 |
Incontinence supply;
miscellaneous |
* |
A4388 |
Indwelling catheter; foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each |
1 ea/mo |
A4340 |
Indwelling catheter specialty type, (e.g., coudé, mushroom, wing, etc.), each |
1 ea/mo |
A4344 |
Indwelling catheter, foley type, two-way, all silicone, each |
1 ea/mo |
A4346 |
Indwelling catheter; foley type, three-way for continuous irrigation, each |
1 ea/mo |
A4349 |
Male external catheter, with or without adhesive,
disposable, each |
35 ea/mo |
A4351 |
Intermittent urinary catheter; straight tip, with or
without coating (Teflon, silicone, silicone elastomer,
or hydrophilic, etc.), each |
200 ea/mo |
A4352 |
Intermittent urinary catheter; coudé (curved) tip, with or without coating (Teflon, silicone, silicone
elastomeric, or hydrophilic, etc.), each |
200 ea/mo |
A4353 |
Intermittent urinary catheter,
with insertion supplies |
200 ea/mo |
A4354 |
Insertion tray with drainage
bag but without catheter |
1 ea/mo |
A4355 |
Irrigation tubing set for continuous bladder
irrigation through a three-way indwelling foley catheter, each |
1 ea/day |
A4356 |
External urethral clamp or compression device
(not to be used for catheter
clamp), each |
1 ea/3 mo |
A4357 |
Bedside drainage bag, day or night, with or without anti-reflux
device, with or without tube, each |
2 ea/mo |
A4358 |
Urinary drainage bag, leg or abdomen, vinyl, with or
without tube, with straps, each |
2 ea/mo |
A4365 |
Adhesive remover wipes, any
type, per 50 |
* |
A4402 |
Lubricant, per ounce |
* |
A4450 |
Tape, non-waterproof, per 18
square inches |
10 units
(18 sq in/mo |
A4452 |
Tape, waterproof, per 18 square
inches |
10 units
(18 sq in/mo |
A4455 |
Adhesive remover or solvent (for tape, cement, or
other adhesive),
per ounce |
* |
A4520 |
Incontinence garment, any type
(e.g., brief, diaper), each |
* |
A4554 |
Disposable underpads,
all sizes |
* |
A5102 |
Bedside drain bottle with or without tubing, rigid
or 1 ea/3 mo
expandable, each |
1 ea/3 mo |
A5105 |
Urinary suspensory;
with leg bag, with or without tube, each |
* |
A5112 |
Urinary leg bag; latex |
1 ea/mo |
A5113 |
Leg strap; latex, replacement
only, per set |
* |
A5114 |
Leg strap, foam or fabric,
replacement only, per set |
* |
A5131 |
Appliance cleaner, incontinence and ostomy 1 (16 oz)/mo
appliances, per 16 ounce |
1 (16
oz)/mo |
A5200 |
Percutaneous catheter/tube anchoring device, adhesive ✳
skin attachment |
* |