incont prod brief

Incontinence Products: Briefs, Disposable 1

CThis section lists the billing codes and units for disposable briefs. In this section, “MAC” refers to the maximum acquisition cost and “UPN” refers to the Universal Product Number. For additional help, refer to the Incontinence Medical Supplies: An Overview section of this manual.

Billing Requirements Billing for disposable briefs is restricted to the contracted items in this section. Claims billed for disposable briefs must include the product’s UPN and UPN Qualifier, as published in this manual, for reimbursement unless otherwise noted. See the Incontinence Medical Supplies Example: CMS-1500 section for additional help.

DISPOSABLE BRIEFS

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

YOUTH DISPOSABLE BRIEFS

Limited to no more than 200 in a 27-day period, without authorization.

First Quality Products

FQP Full Mat Adult Brief PV-015 ON

UP

90891500277

090891500277

T4533 9997QYU $0.3064 ea *

Hospital Specialty

At Ease Brief 80096 UP 075289800962 T4533 9997QYV $0.3064 ea

Ideal Brands

Ideal Care Full Mat IC-2060 UP 873347000015 T4533 9997Q3B $0.3064 ea

Ideal Care Trim Mat IC-4060 UP 873347000114 T4533 9997Q3B $0.3064 ea

Ideal Care-Ultra IC-4060-Ultra UP 873347001753 T4533 9997Q3B $0.3064 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable February 2010

incont prod brief

2

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

MMS-A Medical Supply Company

Adult Brief Super Full Mat 60031MMS ON

UP

23734220056

023734220056

T4533 9997Q2K $0.3064 ea *

Principle Business Enterprises

Select Brief 2666 HI M18326662B T4533 9997QTJ $0.3064 ea

Tranquility SlimLine Brief 2166 HI M183216626 T4533 9997QTJ $0.3064 ea

SCA Personal Care

TENA Brief 61166 UK 10768702611203 T4533 $0.3064 ea

Whitestone

Dignity UltraShield Plus 43090 UP 078459430907 T4533 9997QWH $0.3064 ea

UltraShield Plus 44090 UP 078459440906 T4533 9997QWH $0.3064 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable February 2010

incont prod brief

3

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

SMALL DISPOSABLE BRIEFS

Limited to no more than 200 in a 27-day period, without authorization.

Dependable Incontinence Supply

Prevey 92717 UP 094922665751 T4521 9997T3N $0.3150 ea

First Quality Products, Inc.

FQP Full Mat Adult Brief PV-011 ON

UP

90891500260

090891500260

T4521 9997TYU $0.3150 ea *

Hospital Specialty

At Ease Premium Plus Brief 91096 UP 075289918124 T4521 9997TYV $0.3150 ea

Humanicare

Dignity Plus Fitted Brief 30086 UP 044156300867 T4521 9997TVS $0.3150 ea

Ideal Brands

Ideal Care Full Mat IC-2062 UP 873347000039 T4521 9997T3B $0.3150 ea

Ideal Care Trim Mat IC-4062 UP 873347000138 T4521 9997T3B $0.3150 ea

Ideal Care-Ultra IC-4062-Ultra UP 873347001760 T4521 9997T3B $0.3150 ea

MMS-A Medical Supply Company

MMS Cloth-Like Brief 66032MMS UK 10694393126521 T4521 9997T2K $0.3150 ea

Adult Brief Super Full Mat 60032MMS ON

UP

23734220063

023734220063

T4521 9997T2K $0.3150 ea *

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable February 2010

incont prod brief

4

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

Principle Business Enterprises

Select Brief 2620 HI M183262022 T4521 9997TTJ $0.3150 ea

Tranquility SlimLine Brief 2120 HI M18321202 T4521 9997TTJ $0.3150 ea

Providers Choice Daytime Plus

Daytime Plus LA12440 UP 657060124407 T4521 9997T3P $0.3150 ea

Active Brief LA22440 UP 657060224404 T4521 $0.3150 ea *

SCA Personal Care

TENA Brief 66100 UK 10768702661000 T4521 9997T2H $0.3150 ea

TENA Brief - Discreet 66150 UK 10768702661505 T4521 9997T2H $0.3150 ea

Whitestone

Dignity UltraShield Plus 36110 UP 078459361102 T4521 9997TWH $0.3150 ea

UltraShield Plus 43190 UP 078459431904 T4521 9997TWH $0.3150 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable March 2010

incont prod brief

5

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

MEDIUM DISPOSABLE BRIEFS

Limited to no more than 192 in a 27-day period, without authorization.

Dependable Incontinence Supply

Prevey 93225 UP 094922665805 T4522 9997W3N $0.3600 ea

First Quality

IBF Full Mat Adult Brief IBF-012 ON

UP

90891100255

090891100255

T4522 9997WYU $0.3600 ea *

Nu-Fit Breathable Adult Brief NU-012 ON

UP

90891246144

090891246144

T4522 9997WYU $0.3600 ea *

Per-Fit PF-012 ON

UP

90891246182

090891246182

T4522 9997WYU $0.3600 ea *

Prevail PVB-012 ON

UP

90891246168

090891246168

T4522 9997WYU $0.3600 ea *

FQP Full Mat Adult Brief IB-012 ON

UP

90891246205

090891246205

T4522 9997WYU $0.3600 ea *

Breathable T-shape T-012 ON

UP

90891010004

090891010004

T4522 9997WYU $0.3600 ea *

Hospital Specialty

At Ease Premium Plus Brief 92096 UP 075289928123 T4522 9997WYV $0.3600 ea

At Ease Supra-Fit Brief 92096SF UP 075289770364 T4522 9997WYV $0.3600 ea

At Ease Special Brief 72096 UP 075289728129 T4522 9997WYV $0.3600 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable February 2010

incont prod brief

6

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

Ideal Brands

Ideal Care Full Mat IC-2064 UP 873347000053 T4522 9997W3B $0.3600 ea

Ideal Care Trim Mat IC-4064 UP 873347000152 T4522 9997W3B $0.3600 ea

Ideal Care-Ultra IC-4064-Ultra UP 873347001777 T4522 9997W3B $0.3600 ea

McKesson Medical Surgical

Stay Dry Performance Adult Brief 50-14701/1 UK 40612479170696 T4522 $0.3600 ea

Medline

Protection Plus Contour Brief MSC94000A UK 40080196746355 T4522 9997WZH $0.3600 ea

Ultrasoft Brief MSC**97000 UK 40080196735885 T4522 9997WZH $0.3600 ea

UltraClass Brief Cloth Cover ULTRACLASSMD UK 40080196315421 T4522 9997WZH $0.3600 ea

MMS-A Medical Supply Company

Adult Brief Heavy Trim Mat 60043MMS ON

UP

23734220100

023734220100

T4522 9997W2K $0.3600 ea *

Adult Brief Super Full Mat 60033MMS ON

UP

23734220070

023734220070

T4522 9997W2K $0.3600 ea *

MMS Cloth-Like Brief 66033MMS UK 10694393126538 T4522 9997W2K $0.3600 ea

Presto

Adult Ultra Brief ABB21020 UP 185211000139 T4522 $0.3600 ea

Principle Business Enterprises

Select Brief 2624 HI M183262425 T4522 9997WTJ $0.3600 ea

Tranquility SlimLine Brief 2122 HI M18321222 T4522 9997WTJ $0.3600 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable February 2010

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7

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

Providers Choice Daytime Plus

Daytime Plus LA12450 UP 657060124506 T4522 9997W3P $0.3600 ea

Active Brief LA22450 UP 657060224503 T4522 $0.3600 ea *

San Pablo Commercial Corporation

SPC Comfrey Adult Diaper SPC-20172 EN 6928140302041 T4522 9997W3Q $0.3600 ea

SCA Personal Care

TENA Classic Plus 67713 UK 10768702677131 T4522 9997W2H $0.3600 ea

TENA Classic Plus - Discreet 68115 UK 10768702681152 T4522 9997W2H $0.3600 ea

Whitestone

Ultrashield Extra 36310 UP 078459363106 T4522 9997WWH $0.3600 ea

Dignity UltraSure Plus 33390 UP 078459333901 T4522 9997WWH $0.3600 ea

Dignity Compose 42390 UP 078459423909 T4522 9997WWH $0.3600 ea

Dignity UltraShield Plus 43390 UP 078459433908 T4522 9997WWH $0.3600 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable March 2010

incont prod brief

8

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

REGULAR DISPOSABLE BRIEFS

Limited to no more than 192 in a 27-day period, without authorization.

First Quality

Per-Fit PF-016 ON

UP

90891258109

090891258109

T4522 9907KYU $0.3600 ea *

Prevail PVB-016 ON

UP

90891268108

090891268108

T4522 9907KYU $0.3600 ea *

Hospital Specialty

At Ease Special Briefs 75080 UP 075289750809 T4522 9907KYV $0.3600 ea

At Ease Premium Plus Brief 95080 UP 075289950803 T4522 9907KYV $0.3600 ea

Medline

Protection Plus Contour Brief MSC94400A UK 40080196746362 T4522 9907KZH $0.3600 ea

Presto

Adult Ultra Brief ABB21030 UP 185211000146 T4522 $0.3600 ea

Adult Ultra Brief NB20250 ON 00459202505 T4522 9907K2P $0.3600 ea *

SCA Personal Care

TENA Classic Plus 67714 UK 10768702677148 T4522 9907K2H $0.3600 ea

Whitestone

Dignity UltraSure Plus 33490 UP 078459334908 T4522 9907KWH $0.3600 ea

Dignity Compose 42490 UP 078459424906 T4522 9907KWH $0.3600 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable February 2010

incont prod brief

9

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

LARGE DISPOSABLE BRIEFS

Limited to no more than 216 in a 27-day period, without authorization.

Dependable Incontinence Supply

Prevey 93830 UP 094922665799 T4523 9997Y3N $0.4800 ea

First Quality

IBF Full Mat Adult Brief IBF-013 ON

UP

90891100262

090891100262

T4523 9997YYU $0.4800 ea *

Nu-Fit Breathable Adult Brief NU-013 ON

UP

90891246151

090891246151

T4523 9997YYU $0.4800 ea *

Per-Fit PF-013 ON

UP

90891246199

090891246199

T4523 9997YYU $0.4800 ea *

Prevail PVB-013 ON

UP

90891246175

090891246175

T4523 9997YYU $0.4800 ea *

FQP Full Mat Adult Brief IB-013 ON

UP

90891246212

090891246212

T4523 9997YYU $0.4800 ea *

Breathable T-shape T-013 ON

UP

90891010011

090891010011

T4523 9997YYU $0.4800 ea *

Hospital Specialty

At Ease Premium Plus Brief 93072 UP 075289936128 T4523 9997YYV $0.4800 ea

At Ease Special Brief 73072 UP 075289736124 T4523 9997YYV $0.4800 ea

At Ease Breathable Special Brief 73072SF UP 075289770326 T4523 9997YYV $0.4800 ea

At Ease Supra-Fit Brief 93072SF UP 075289770388 T4523 9997YYV $0.4800 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable February 2010

incont prod brief

10

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

Humanicare

Dignity Plus Fitted Brief 30088 UP 044156300881 T4523 9997YVS $0.4800 ea

Ideal Brands

Ideal Care Full Mat IC-2066 UP 873347000077 T4523 9997Y3B $0.4800 ea

Ideal Care Trim Mat IC-4066 UP 873347000176 T4523 9997Y3B $0.4800 ea

Ideal Care-Ultra IC-4066-Ultra UP 873347001784 T4523 9997Y3B $0.4800 ea

McKesson Medical Surgical

Stay Dry Performance Adult Brief 50-14705/1 UK 40612479170719 T4523 $0.4800 ea

Medline

UltraSoft Brief MSC**97500 UK 40080196735892 T4523 9997YZH $0.4800 ea

Protection Plus Contour Brief MSC94500A UK 40080196291770 T4523 $0.4800 ea

MMS-A Medical Supply Company

Adult Brief Super Full Mat 60034MMS ON

UP

23734220087

023734220087

T4523 9997Y2K $0.4800 ea *

Adult Brief Heavy Trim Mat 60044MMS ON

UP

23734220117

023734220117

T4523 9997Y2K $0.4800 ea *

MMS Cloth-Like Brief 66034MMS UK 10694393126545 T4523 9997Y2K $0.4800 ea

Presto

Adult Ultra Brief ABB21040 UP 185211000153 T4523 $0.4800 ea *

Principle Business Enterprises

Select Brief 2634 HI M183263426 T4523 9997YTJ $0.4800 ea

Tranquility SlimLine Brief 2132 HI M18321322 T4523 9997YTJ $0.4800 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable February 2010

incont prod brief

11

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

Providers Choice Daytime Plus

Daytime Plus LA12460 UP 657060124605 T4523 9997Y3P $0.4800 ea

Active Brief LA22460 UP 657060224602 T4523 $0.4800 ea *

San Pablo Commercial Corporation

SPC Comfrey Adult Diaper SPC-20272 EN 6928140302393 T4523 9997Y3Q $0.4800 ea

SCA Personal Care

TENA Classic Plus 67813 UK 10768702678138 T4523 9997Y2H $0.4800 ea

TENA Classic Plus - Discreet 68116 UK 10768702681169 T4523 9997Y2H $0.4800 ea

Whitestone

UltraShield 34592 UP 078459345928 T4523 9997YWH $0.4800 ea

UltraShield Extra 36510 UP 078459365100 T4523 9997YWH $0.4800 ea

Dignity UltraSure Plus 33590 UP 078459335905 T4523 9997YWH $0.4800 ea

Dignity Compose 42590 UP 078459425903 T4523 9997YWH $0.4800 ea

Dignity UltraShield Plus 43590 UP 078459435902 T4523 9997YWH $0.4800 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable March 2010

incont prod brief

12

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

EXTRA-LARGE DISPOSABLE BRIEFS

Limited to no more than 192 in a 27-day period, without authorization.

Dependable Incontinence Supply

Prevey 93832 UP 094922665782 T4524 9907M3N $0.4800 ea

First Quality

Per-Fit PF-014 ON

UP

90891258086

090891258086

T4524 9907MYU $0.4800 ea *

FQP Full Mat Adult Brief IB-014 ON

UP

90891100644

090891100644

T4524 9907MYU $0.4800 ea *

Prevail PVB-014 ON

UP

90891264155

090891264155

T4524 9907MYU $0.4800 ea *

FQP Full Mat Adult Brief IBF-014 ON

UP

90891120642

090891120642

T4524 9907MYU $0.4800 ea *

Nu-Fit Breathable Adult Brief NU-014 ON

UP

90891248087

090891248087

T4524 9907MYU $0.4800 ea *

Hospital Specialty

At Ease Special Brief 74060 UP 075289740602 T4524 9907MYV $0.4800 ea

At Ease Premium Plus Brief 94064 UP 075289940644 T4524 9907MYV $0.4800 ea

At Ease Supra-Fit Brief 94060SF UP 075289770395 T4524 9907MYV $0.4800 ea

At Ease Supra-Fit Brief Extra Extra Large

96048SF UP 075289770401 T4524 9907MYV $0.4800 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable February 2010

incont prod brief

13

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

Humanicare

Dignity Plus Fitted Brief 30089 UP 044156300898 T4524 9907MVS $0.4800 ea

Ideal Brands

Ideal Care Full Mat IC-2068 UP 873347000091 T4524 9907M3B $0.4800 ea

Ideal Care Trim Mat IC-4068 UP 873347000190 T4524 9907M3B $0.4800 ea

Ideal Care-Ultra IC-4068-Ultra UP 873347001791 T4524 9907M3B $0.4800 ea

McKesson Medical Surgical

Stay Dry Performance Adult Brief 50-14707/1 UP 40612479170733 T4524 $0.4800 ea

Medline

UltraSoft Brief MSC**97605 UK 40080196735908 T4524 9907MZH $0.4800 ea

Protection Plus Contour Brief MSC94600A UK 40080196291763 T4524 $0.4800 ea

Ultra-Soft Plus Brief XXL ULTRAPLUS XXL

UK 40080196325093 T4524 $0.4800 ea

MMS-A Medical Supply Company

Adult Brief Heavy Trim Mat 60045MMS UP 023734220124 T4524 9907M2K $0.4800 ea

Adult Brief Super Full Mat 60035MMS UP 023734220094 T4524 9907M2K $0.4800 ea

MMS Cloth-Like Brief 66035MMS UK 10694393126552 T4524 9907M2K $0.4800 ea

Principle Business Enterprises

Select Brief 2635 HI M183263527 T4524 9907MTJ $0.4800 ea

Tranquility SlimLine Brief 2134 HI M183213421 T4524 9907MTJ $0.4800 ea

2 – Incontinence Products: Briefs, Disposable September 2009

incont prod brief

14

Description

Item Number (Reference only)

UPN Qualifier UPN

Billing Code (HCPCS)

Old Billing Code: (Prior to 4/1/09) MAC

Unit of Measure

Presto

Adult Ultra Brief ABB21050 UP 185211001610 T4524 $0.4800 ea

Adult Ultra Brief NB20400 ON 00459204004 T4524 9907M2P $0.4800 ea *

Providers Choice Daytime Plus

Daytime Plus Premium Brief LA12470 UP 657060124704 T4524 9907M3P $0.4800 ea

Active Brief LA22470 UP 657060224701 T4524 $0.4800 ea *

San Pablo Commercial Corporation

SPC Comfrey Adult Diaper SPC-20360 EN 6928140302409 T4524 9907M3Q $0.4800 ea

SCA Personal Care

TENA Classic Plus 67914 UK 10768702679142 T4524 9907M2H $0.4800 ea

TENA Classic Plus - Discreet 68132 UK 10768702681329 T4524 9907M2H $0.4800 ea

Whitestone

UltraShield 34692 UP 078459346925 T4524 9907MWH $0.4800 ea

Dignity UltraSure Plus 33690 UP 078459336902 T4524 9907MWH $0.4800 ea

Dignity Compose 42690 UP 078459426900 T4524 9907MWH $0.4800 ea

Dignity UltraShield Plus 43690 UP 078459436909 T4524 9907MWH $0.4800 ea

* Effective April 1, 2010

2 – Incontinence Products: Briefs, Disposable March 2010