Medical Supply Products: Urologicals � Intermittent Catheters

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					Medical Supply Products: Urologicals –                                                                                                            mc sup prod uro int g
Intermittent Catheters – Manufacturers G thru M                                                                                                                           1
This section lists the billing codes and units of measure for contracted intermittent urinary catheters manufactured by companies with names that begin with
the letters G through M. In this section, “UPN” refers to the Universal Product Number, “MAC” refers to the Maximum Acquisition Cost and “MAPC” refers to
the Maximum Allowable Product Cost. For additional help, refer to the Medical Supplies: An Overview section in this manual.


Claim Requirements                        Claims billed for intermittent urinary catheters require the product’s UPN and UPN Qualifier, as published in this manual,
                                          for reimbursement unless otherwise noted. Billing for intermittent catheters is restricted to the items on the contract list.
                                          See the Medical Supplies: Billing Examples section for additional help.



Authorization                             Intermittent catheter sterile kits not listed require a Treatment Authorization Request (TAR) using billing
                                          code A4353.



Billing Limitations                       Intermittent urinary catheters are limited to no more than 150 catheters in a 27-day period, without authorization.



Medicare Billing Required                 If the recipient is eligible for Medicare, all urological products must be billed to Medicare before billing Medi-Cal.




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                                   November 2010
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CONTRACTED INTERMITTENT URINARY CATHETERS

                                                                     Item Number                        Billing
                                                                     (reference         UPN             Code                    Unit of
Description                                                          only)              Qualifier UPN   (HCPCS)    MAC    MAPC Measure
Go Medical
INTERMITTENT CATHETERS, STRAIGHT TIP, WITH ATTACHED COLLECTION BAGS
  O'Neil Intermittent Sterile Field Catheter - 8 Fr Peel  AAM8008P HI M217AAM8008P0                     A4351     $3.45   $3.45     ea
  Pouch - Gamma Sterilized, each
    Box/100                                               AAM8008P HI M217AAM8008P1                     A4351     $3.45   $3.45     ea
  O'Neil Intermittent Sterile Field Catheter - 10 Fr Peel AAM8010P HI M217AAM8010P0                     A4351     $3.45   $3.45     ea
  Pouch - Gamma Sterilized, each
    Box/100                                               AAM8010P HI M217AAM8010P1                     A4351     $3.45   $3.45     ea
  O'Neil Intermittent Sterile Field Catheter - 12 Fr Peel AAM8012P HI M217AAM8012P0                     A4351     $3.45   $3.45     ea
  Pouch - Gamma Sterilized, each
    Box/100                                               AAM8012P HI M217AAM8012P1                     A4351     $3.45   $3.45     ea
  O'Neil Intermittent Sterile Field Catheter - 14 Fr Peel AAM8014P HI M217AAM8014P0                     A4351     $3.45   $3.45     ea
  Pouch - Gamma Sterilized, each
    Box/100                                               AAM8014P HI M217AAM8014P1                     A4351     $3.45   $3.45     ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                November 2010
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                                                          Item Number                                              Billing
                                                          (reference                    UPN                        Code                    Unit of
Description                                               only)                         Qualifier UPN              (HCPCS)    MAC    MAPC Measure
  O'Neil Intermittent Sterile Field Catheter - 16 Fr Peel AAM8016P                       HI        M217AAM8016P0    A4351    $3.45   $3.45    ea
  Pouch - Gamma Sterilized, each
    Box/100                                               AAM8016P                       HI      M217AAM8016P1     A4351     $3.45   $3.45         ea
  O'Neil Intermittent Sterile Field Catheter- 18 Fr Peel AAM8018P                        HI      M217AAM8018P0     A4351     $3.45   $3.45         ea
  Pouch - Gamma Sterilized, each
    Box/100                                               AAM8018P                       HI      M217AAM8018P1     A4351     $3.45   $3.45         ea
  O'Neil Intermittent Sterile Field Catheter - 8 Fr Peel  AAM8008PE                      HI      M217AAM8008PE0    A4351     $3.45   $3.45         ea
  Pouch -ETO, each
    Box/100                                               AAM8008PE                      HI      M217AAM8008PE1    A4351     $3.45   $3.45         ea
  O'Neil Intermittent Sterile Field Catheter - 10 Fr Peel AAM8010PE                      HI      M217AAM8010PE0    A4351     $3.45   $3.45         ea
  Pouch - ETO Sterilized, each
    Box/100                                               AAM8010PE                      HI      M217AAM8010PE1    A4351     $3.45   $3.45         ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                              November 2010
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                                                          Item Number                                             Billing
                                                          (reference                    UPN                       Code                    Unit of
Description                                               only)                         Qualifier UPN             (HCPCS)    MAC    MAPC Measure
  O'Neil Intermittent Sterile Field Catheter - 12 Fr Peel AAM8012PE                      HI        M217AAM8012PE0 A4351     $3.45   $3.45    ea
  Pouch - ETO Sterilized, each
    Box/100                                               AAM8012PE                      HI     M217AAM8012PE1    A4351     $3.45   $3.45     ea
  O'Neil Intermittent Sterile Field Catheter - 14 Fr Peel AAM8014PE                      HI     M217AAM8014PE0    A4351     $3.45   $3.45     ea
  Pouch - ETO Sterilized, each
    Box/100                                               AAM8014PE                      HI     M217AAM8014PE1    A4351     $3.45   $3.45     ea
  O'Neil Intermittent Sterile Field Catheter - 16 Fr Peel AAM8016PE                      HI     M217AAM8016PE0    A4351     $3.45   $3.45     ea
  Pouch - ETO Sterilized, each
    Box/100                                               AAM8016PE                      HI     M217AAM8016PE1    A4351     $3.45   $3.45     ea
  O'Neil Intermittent Sterile Field Catheter - 18 Fr Peel AAM8018PE                      HI     M217AAM8018PE0    A4351     $3.45   $3.45     ea
  Pouch - ETO Sterilized, each
    Box/100                                               AAM8018PE                      HI     M217AAM8018PE1    A4351     $3.45   $3.45     ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                          November 2010
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                                                                     Item Number                        Billing
                                                                     (reference         UPN             Code                    Unit of
Description                                                          only)              Qualifier UPN   (HCPCS)    MAC    MAPC Measure
Hollister
INTERMITTENT CATHETERS, STRAIGHT TIP, NON-HYDROPHILIC, WITHOUT ATTACHED COLLECTION BAGS
Apogee IC, 6 Fr, 15", each                  1007        UP      187168000353    A4351                             $0.78   $1.00         ea
  (30)                                                  UP      610075176915    A4351                             $0.78   $1.00        ea *
  Shelf/30                                  1007        UK      10187168100357  A4351                             $0.78   $1.00         ea
                                                        UK      10610075176578  A4351                             $0.78   $1.00        ea *
  Case/540                                  1007        UK      20187168100354  A4351                             $0.78   $1.00         ea
                                                        UK      20610075176575  A4351                             $0.78   $1.00        ea *
Apogee IC, 8 Fr, 6", each                   1016        UP      187168000360    A4351                             $0.78   $1.00         ea
  (30)                                                  UP      610075176922    A4351                             $0.78   $1.00        ea *
  Shelf/30                                  1016        UK      10187168100364  A4351                             $0.78   $1.00         ea
                                                        UK      10610075176585  A4351                             $0.78   $1.00        ea *
  Case/450                                  1016        UK      20187168100361  A4351                             $0.78   $1.00         ea
                                                        UK      20610075176582  A4351                             $0.78   $1.00        ea *

*     Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters Manufacturers G – M                                                         September 2011
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                                                                     Item Number                                    Billing
                                                                     (reference         UPN                         Code                    Unit of
Description                                                          only)              Qualifier UPN               (HCPCS)    MAC    MAPC Measure
Apogee IC, 8 Fr, 16", each                                           1018                UP        187168000377      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176939      A4351    $0.78   $1.00    ea
  Shelf/30                                                           1018                UK        10187168100371    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176592    A4351    $0.78   $1.00    ea
    Case/540                                                         1018                UK        20187168100378    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176599    A4351    $0.78   $1.00    ea
Apogee IC, 8 Fr, 10”, each                                           1020                UP        187168000582      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176946      A4351    $0.78   $1.00    ea
  Shelf/30                                                           1020                UK        10187168100586    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176608    A4351    $0.78   $1.00    ea
    Case/540                                                         1020                UK        20187168100583    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176605    A4351    $0.78   $1.00    ea
Apogee IC, 10 Fr, 6", each                                           1033                UP        187168000391      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176953      A4351    $0.78   $1.00    ea
  Shelf/30                                                           1033                UK        10187168100395    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176615    A4351    $0.78   $1.00    ea
    Case/450                                                         1033                UK        20187168100392    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176612    A4351    $0.78   $1.00    ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters Manufacturers G – M                                                                 February 2012
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                                                                     Item Number                                    Billing
                                                                     (reference         UPN                         Code                    Unit of
Description                                                          only)              Qualifier UPN               (HCPCS)    MAC    MAPC Measure
Apogee IC, 10 Fr, 16", each                                          1034                UP        187168000407      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176960      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1034                UK        10187168100401    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176622    A4351    $0.78   $1.00   ea *
    Case/540                                                         1034                UK        20187168100408    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176629    A4351    $0.78   $1.00   ea *
Apogee IC, 10 Fr, 16", Soft, each                                    1036                UP        187168000605      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176830      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1036                UK        10187168100609    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176493    A4351    $0.78   $1.00   ea *
    Case/540                                                         1036                UK        20187168100606    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176490    A4351    $0.78   $1.00   ea *
Apogee IC, 10 Fr, 10", each                                          1040                UP        187168000599      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176977      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1040                UK        10187168100593    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176639    A4351    $0.78   $1.00   ea *
    Case/540                                                         1040                UK        20187168100590    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176636    A4351    $0.78   $1.00   ea *

*    Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters Manufacturers G – M                                                              September 2011
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                                                                     Item Number                                    Billing
                                                                     (reference         UPN                         Code                    Unit of
Description                                                          only)              Qualifier UPN               (HCPCS)    MAC    MAPC Measure
Apogee IC, 12 Fr, 16", Soft, each                                    1046                UP        187168000421      A4351    $0.78   $1.00    ea
  (30)                                                                                  UP         610075176779      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1046                UK        10187168100425    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176431    A4351    $0.78   $1.00   ea *
    Case/540                                                         1046                UK        20187168100422    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176438    A4351    $0.78   $1.00   ea *
Apogee IC, 12 Fr, 6", each                                           1047                UP        187168000438      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176786      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1047                UK        10187168100432    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176448    A4351    $0.78   $1.00   ea *
    Case/450                                                         1047                UK        20187168100439    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176445    A4351    $0.78   $1.00   ea *
Apogee IC, 12 Fr, 16", each                                          1048                UP        187168000445      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176793      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1048                UK        10187168100449    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176455    A4351    $0.78   $1.00   ea *
    Case/540                                                         1048                UK        20187168100446    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176452    A4351    $0.78   $1.00   ea *

*    Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                        September 2011
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                                                                                                                                                               9

                                                                     Item Number                                    Billing
                                                                     (reference         UPN                         Code                    Unit of
Description                                                          only)              Qualifier UPN               (HCPCS)    MAC    MAPC Measure
Apogee IC, 12 Fr, 16", Curved Package, each                          1049                UP        187168000452      A4351    $0.78   $1.00    ea
  (50)                                                                                   UP        610075176984      A4351    $0.78   $1.00   ea *
  Shelf/50                                                           1049                UK        10187168100456    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176646    A4351    $0.78   $1.00   ea *
    Case/300                                                         1049                UK        20187168100453    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176643    A4351    $0.78   $1.00   ea *
Apogee IC, 12 Fr, 16", Latex, each                                   1051                UP        187168000629      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176847      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1051                UK        10187168100623    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176509    A4351    $0.78   $1.00   ea *
    Case/540                                                         1051                UK        20187168100620    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176506    A4351    $0.78   $1.00   ea *
Apogee IC, 14 Fr, 16", Soft, each                                    1061                UP        187168000476      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176724      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1061                UK        10187168100470    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176387    A4351    $0.78   $1.00   ea *
    Case/540                                                         1061                UK        20187168100477    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176384    A4351    $0.78   $1.00   ea *

*    Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters Manufacturers G – M                                                              September 2011
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                                                                     Item Number                                    Billing
                                                                     (reference         UPN                         Code                    Unit of
Description                                                          only)              Qualifier UPN               (HCPCS)    MAC    MAPC Measure
Apogee IC, 14 Fr, 6", each                                           1062                UP        187168000483      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176731      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1062                UK        10187168100487    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176394    A4351    $0.78   $1.00   ea *
    Case/450                                                         1062                UK        20187168100484    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176391    A4351    $0.78   $1.00   ea *
Apogee IC, 14 Fr, 6", Without Adapter, each                          1063                UP        187168000490      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176748      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1063                UK        10187168100494    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176400    A4351    $0.78   $1.00   ea *
    Case/450                                                         1063                UK        20187168100491    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176407    A4351    $0.78   $1.00   ea *
Apogee IC, 14 Fr, 16", each                                          1064                UP        187168000506      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP        610075176755      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1064                UK        10187168100500    A4351    $0.78   $1.00    ea
                                                                                         UK        10610075176417    A4351    $0.78   $1.00   ea *
    Case/540                                                         1064                UK        20187168100507    A4351    $0.78   $1.00    ea
                                                                                         UK        20610075176414    A4351    $0.78   $1.00   ea *

*    Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                        September 2011
                                                                                                                                          mc sup prod uro int g
                                                                                                                                                            11

                                                                     Item Number                                   Billing
                                                                     (reference         UPN                        Code                    Unit of
Description                                                          only)              Qualifier UPN              (HCPCS)    MAC    MAPC Measure
Apogee IC, 14 Fr, 16", Curved Package, each                          1065                UP       187168000513      A4351    $0.78   $1.00     ea
  (50)                                                                                   UP       610075177004      A4351    $0.78   $1.00   ea *
  Shelf/50                                                           1065                UK       10187168100517    A4351    $0.78   $1.00     ea
                                                                                         UK       10610075176660    A4351    $0.78   $1.00   ea *
    Case/300                                                         1065                UK       20187168100514    A4351    $0.78   $1.00     ea
                                                                                         UK       20610075176667    A4351    $0.78   $1.00    ea*
Apogee IC, 14 Fr, 16", Latex, each                                   1067                UP       187168000636      A4351    $0.78   $1.00     ea
  (30)                                                                                   UP       610075176854      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1067                UK       10187168100630    A4351    $0.78   $1.00     ea
                                                                                         UK       10610075176516    A4351    $0.78   $1.00   ea *
    Case/540                                                         1067                UK       20187168100637    A4351    $0.78   $1.00     ea
                                                                                         UK       20610075176513    A4351    $0.78   $1.00   ea *
Apogee IC, 16 Fr, 16", each                                          1082                UP       187168000544      A4351    $0.78   $1.00     ea
  (30)                                                                                   UP       610075176809      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1082                UK       10187168100548    A4351    $0.78   $1.00     ea
                                                                                         UK       10610075176462    A4351    $0.78   $1.00   ea *
    Case/540                                                         1082                UK       20187168100545    A4351    $0.78   $1.00     ea
                                                                                         UK       20610075176469    A4351    $0.78   $1.00   ea *

*    Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters Manufacturers G – M                                                             September 2011
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                                                                     Item Number                                   Billing
                                                                     (reference         UPN                        Code                    Unit of
Description                                                          only)              Qualifier UPN              (HCPCS)    MAC    MAPC Measure
Apogee IC, 16 Fr, 16", Soft, each                                    1083                UP       187168000612      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP       610075176762      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1083                UK       10187168100616    A4351    $0.78   $1.00    ea
                                                                                         UK       10610075176424    A4351    $0.78   $1.00   ea *
    Case/540                                                         1083                UK       20187168100613    A4351    $0.78   $1.00    ea
                                                                                         UK       20610075176421    A4351    $0.78   $1.00   ea *
Apogee IC, 16 Fr, 16", Latex, each                                   1084                UP       187168000643      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP       610075176861      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1084                UK       10187168100647    A4351    $0.78   $1.00    ea
                                                                                         UK       10610075176523    A4351    $0.78   $1.00   ea *
    Case/540                                                         1084                UK       20187168100644    A4351    $0.78   $1.00    ea
                                                                                         UK       20610075176520    A4351    $0.78   $1.00   ea *




*    Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                       September 2011
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                                                                                                                                                            13

                                                                     Item Number                                   Billing
                                                                     (reference         UPN                        Code                    Unit of
Description                                                          only)              Qualifier UPN              (HCPCS)    MAC    MAPC Measure
Apogee IC, 18 Fr, 16", each                                          1096                UP       187168000575      A4351    $0.78   $1.00    ea
  (30)                                                                                   UP       610075177059      A4351    $0.78   $1.00   ea *
  Shelf/30                                                           1096                UK       10187168100579    A4351    $0.78   $1.00    ea
                                                                                         UK       10610075176714    A4351    $0.78   $1.00   ea *
    Case/540                                                         1096                UK       20187168100576    A4351    $0.78   $1.00    ea
                                                                                         UK       20610075176711    A4351    $0.78   $1.00   ea *
Apogee IC, 14 Fr, 16", Soft, Curved Package, each                    1074A               UP       187168000537      A4351    $0.78   $1.00    ea
  (50)                                                                                   UP       610075177028      A4351    $0.78   $1.00   ea *
  Shelf/50                                                           1074A               UK       10187168100531    A4351    $0.78   $1.00    ea
                                                                                         UK       10610075176684    A4351    $0.78   $1.00   ea *
    Case/300                                                         1074A               UK       20187168100538    A4351    $0.78   $1.00    ea
                                                                                         UK       20610075176681    A4351    $0.78   $1.00   ea *

*    Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters Manufacturers G – M                                                             September 2011
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                                                                     Item Number                        Billing
                                                                     (reference         UPN             Code                    Unit of
Description                                                          only)              Qualifier UPN   (HCPCS)   MAC     MAPC Measure
Hollister
INTERMITTENT CATHETERS, STRAIGHT TIP, WITH ATTACHED COLLECTION BAGS
Advance Plus Pre-Lubricated Intermittent Catheter       94064 UK 10610075101945                         A4351     $3.45   $3.45      ea
With Introducer Tip And Urine Bag - Straight, 6 Fr, 16"
Advance Plus Pre-Lubricated Intermittent Catheter       94084 UK 10610075101952                         A4351     $3.45   $3.45      ea
With Introducer Tip And Urine Bag - Straight, 8 Fr, 16"
Advance Plus Pre-Lubricated Intermittent Catheter       94104 UK 10610075101969                         A4351     $3.45   $3.45      ea
With Introducer Tip And Urine Bag - Straight, 10 Fr,
16"
Advance Plus Pre-Lubricated Intermittent Catheter       94124 UK 10610075101976                         A4351     $3.45   $3.45      ea
With Introducer Tip And Urine Bag - Straight, 12 Fr,
16"
Advance Plus Pre-Lubricated Intermittent Catheter       94144 UK 10610075101983                         A4351     $3.45   $3.45      ea
With Introducer Tip And Urine Bag - Straight, 14 Fr,
16"
Advance Plus Pre-Lubricated Intermittent Catheter       94164 UK 10610075101990                         A4351     $3.45   $3.45      ea
With Introducer Tip And Urine Bag - Straight, 16 Fr,
16"
Advance Plus Pre-Lubricated Intermittent Catheter       94184 UK 10610075102010                         A4351     $3.45   $3.45      ea
With Introducer Tip And Urine Bag - Straight, 18 Fr,
16"




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                September 2011
                                                                                                                                               mc sup prod uro int g
                                                                                                                                                                     15

                                                                     Item Number                                     Billing
                                                                     (reference         UPN                          Code                    Unit of
Description                                                          only)              Qualifier   UPN              (HCPCS)    MAC    MAPC Measure
Pre-Lubricated 6 Fr Firm Catheter w/ Collection Bag                  B6F                UP          187168000018     A4351     $3.45   $3.45     ea
                                                                                        UK          20187168100019   A4351     $3.45   $3.45     ea
                                                                                        UK          20610075177459   A4351     $3.45   $3.45   ea *
Pre-Lubricated 8 Fr Firm Catheter w/ Collection Bag                  B8F                UP          187168000032     A4351     $3.45   $3.45     ea
                                                                                        UK          20187168100033   A4351     $3.45   $3.45     ea
                                                                                        UK          20610075177473   A4351     $3.45   $3.45   ea *
Pre-Lubricated 10 Fr Firm Catheter w/ Collection Bag                 B10F               UP          187168000056     A4351     $3.45   $3.45     ea
                                                                                        UK          20187168100057   A4351     $3.45   $3.45     ea
                                                                                        UK          20610075177190   A4351     $3.45   $3.45   ea *
Pre-Lubricated 12 Fr Firm Catheter w/ Collection Bag                 B12F               UP          187168000094     A4351     $3.45   $3.45     ea
                                                                                        UK          20187168100095   A4351     $3.45   $3.45     ea
                                                                                        UK          20610075177077   A4351     $3.45   $3.45   ea *
Pre-Lubricated 12 Fr Red Rubber Catheter                             B12R               UP          187168000117     A4351     $3.45   $3.45     ea
w/ Collection Bag
                                                                                        UK          20187168100118   A4351     $3.45   $3.45         ea
                                                                                        UK          20610075177251   A4351     $3.45   $3.45        ea *
Pre-Lubricated 12 Fr Soft Catheter w/ Collection Bag                 B12S               UP          187168000131     A4351     $3.45   $3.45         ea
                                                                                        UK          20187168100132   A4351     $3.45   $3.45         ea
                                                                                        UK          20610075177091   A4351     $3.45   $3.45        ea *




*   Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                                 September 2011
mc sup prod uro int g
16

                                                                     Item Number                                    Billing
                                                                     (reference         UPN                         Code                    Unit of
Description                                                          only)              Qualifier UPN               (HCPCS)    MAC    MAPC Measure
Pre-Lubricated 14 Fr Firm Catheter w/ Collection Bag                 B14F                UP        187168000179      A4351    $3.45   $3.45    ea
                                                                                         UK        20187168100170    A4351    $3.45   $3.45    ea
                                                                                         UK        20610075177114    A4351    $3.45   $3.45   ea *
Pre-Lubricated 14 Fr Female Catheter w/ Collection                   B14F female         UP        187168000186      A4351    $3.45   $3.45    ea
Bag
                                                                                         UK      20187168100187     A4351     $3.45   $3.45     ea
                                                                                         UK      20610075177145     A4351     $3.45   $3.45    ea *
Pre-Lubricated 14 Fr Red Rubber Catheter                             B14R                UP      187168000223       A4351     $3.45   $3.45     ea
w/ Collection Bag
                                                                                         UK      20187168100224     A4351     $3.45   $3.45     ea
                                                                                         UK      20610075177336     A4351     $3.45   $3.45    ea *
Pre-Lubricated 14 Fr Soft Catheter w/ Collection Bag                 B14S                UP      187168000247       A4351     $3.45   $3.45     ea
                                                                                         UK      20187168100248     A4351     $3.45   $3.45     ea
                                                                                         UK      20610075177152     A4351     $3.45   $3.45    ea *
Pre-Lubricated 16 Fr Firm Catheter w/ Collection Bag                 B16F                UP      187168000285       A4351     $3.45   $3.45     ea
                                                                                         UK      20187168100286     A4351     $3.45   $3.45     ea
                                                                                         UK      20610075177176     A4351     $3.45   $3.45    ea *
Pre-Lubricated 16 Fr Red Rubber Catheter                             B16R                UP      187168000308       A4351     $3.45   $3.45     ea
w/ Collection Bag
                                                                                         UK      20187168100309     A4351     $3.45   $3.45     ea
                                                                                         UK      20610075177411     A4351     $3.45   $3.45    ea *
Pre-Lubricated 18 Fr Firm Catheter w/ Collection Bag                 B18F                UP      187168000322       A4351     $3.45   $3.45     ea
                                                                                         UK      20187168100323     A4351     $3.45   $3.45     ea
                                                                                         UK      20610075177435     A4351     $3.45   $3.45    ea *



*    Effective October 1, 2011



2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                            September 2011
                                                                                                                                  mc sup prod uro int g
                                                                                                                                                       17

                                                                     Item Number                        Billing
                                                                     (reference         UPN             Code                    Unit of
Description                                                          only)              Qualifier UPN   (HCPCS)    MAC    MAPC Measure
Hollister
INTERMITTENT CATHETERS, COUDÉ TIP, NON-HYDROPHILIC, WITHOUT ATTACHED COLLECTION BAGS
Apogee IC, 8 Fr, 16", Coudé, each         1021          UP     187168000650    A4352                              $2.14   $2.14        ea
  (30)                                                  UP     610075176816    A4352                              $2.14   $2.14       ea *
  Shelf/30                                1021          UK     10187168100654  A4352                              $2.14   $2.14        ea
                                                        UK     10610075176479  A4352                              $2.14   $2.14       ea *
  Case/540                                1021          UK     20187168100651  A4352                              $2.14   $2.14        ea
                                                        UK     20610075176476  A4352                              $2.14   $2.14       ea *
Apogee IC, 10 Fr, 16", Coudé, each        1035          UP     187168000667    A4352                              $2.14   $2.14        ea
  (30)                                                  UP     610075176823    A4352                              $2.14   $2.14       ea *
  Shelf/30                                1035          UK     10187168100661  A4352                              $2.14   $2.14        ea
                                                        UK     10610075176486  A4352                              $2.14   $2.14       ea *
  Case/540                                1035          UK     20187168100668  A4352                              $2.14   $2.14        ea
                                                        UK     20610075176483  A4352                              $2.14   $2.14       ea *




*     Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                   September 2011
mc sup prod uro int g
18

Description                                                          Item Number        UPN         UPN              Billing   MAC      MAPC      Unit of
                                                                     (reference         Qualifier                    Code                        Measure
                                                                     only)                                           (HCPCS)
Apogee IC, 12 Fr, 16", Coudé, each                                   1050               UP          187168000469     A4352     $2.14    $2.14         ea
  (30)                                                                                  UP          610075176991      A4352     $2.14    $2.14       ea *
  Shelf/30                                                           1050               UK          10187168100463   A4352     $2.14    $2.14         ea
                                                                                        UK          10610075176653    A4352     $2.14    $2.14       ea *
    Case/540                                                         1050               UK          20187168100460   A4352     $2.14    $2.14         ea
                                                                                        UK          20610075176650    A4352     $2.14    $2.14       ea *
Apogee IC, 14 Fr, 16", Coudé, each                                   1066               UP          187168000520      A4352     $2.14    $2.14        ea
  (30)                                                                                  UP          610075177011      A4352     $2.14    $2.14       ea *
  Shelf/30                                                           1066               UK          10187168100524    A4352     $2.14    $2.14        ea
                                                                                        UK          10610075176677    A4352     $2.14    $2.14       ea *
    Case/540                                                         1066               UK          20187168100521    A4352     $2.14    $2.14        ea
                                                                                        UK          20610075176674    A4352     $2.14    $2.14       ea *




*     Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                                  September 2011
                                                                                                                                                mc sup prod uro int g
                                                                                                                                                                      19

Description                                                          Item Number        UPN         UPN              Billing   MAC     MAPC      Unit of
                                                                     (reference         Qualifier                    Code                       Measure
                                                                     only)                                           (HCPCS)
Apogee IC, 16 Fr, 16", Coudé, each                                    1086               UP         187168000551      A4352    $2.14    $2.14         ea
  (30)                                                                                   UP         610075177035      A4352    $2.14    $2.14        ea *
  Shelf/30                                                           1086                UK         10187168100555    A4352    $2.14    $2.14         ea
                                                                                         UK         10610075176691    A4352    $2.14    $2.14        ea *
    Case/540                                                         1086                UK         20187168100552    A4352    $2.14    $2.14         ea
                                                                                         UK         20610075176698    A4352    $2.14    $2.14        ea *
Apogee IC, 16 Fr, 16", Coudé, Curved Packaging,                      1087                UP         187168000568      A4352    $2.14    $2.14         ea
each
  (50)                                                                                   UP         610075177042     A4352     $2.14    $2.14        ea *
  Shelf/50                                                           1087                UK         10187168100562   A4352     $2.14    $2.14         ea
                                                                                         UK         10610075176707   A4352     $2.14    $2.14        ea *
    Case/300                                                         1087                UK         20187168100569   A4352     $2.14    $2.14         ea
                                                                                         UK         20610075176704   A4352     $2.14    $2.14        ea *
Apogee IC, 18 Fr, 16" Coudé, each                                    1097                UP         187168000674     A4352     $2.14    $2.14         ea
  (30)                                                                                   UP         610075176878     A4352     $2.14    $2.14        ea *
  Shelf/30                                                           1097                UK         10187168100678   A4352     $2.14    $2.14         ea
                                                                                         UK         10610075176530   A4352     $2.14    $2.14        ea *
    Case/540                                                         1097                UK         20187168100675   A4352     $2.14    $2.14         ea
                                                                                         UK         20610075176537   A4352     $2.14    $2.14        ea *

*    Effective October 1, 2011




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                                  September 2011
mc sup prod uro int g
20

                                                                     Item Number                        Billing
                                                                     (reference         UPN             Code                    Unit of
Description                                                          only)              Qualifier UPN   (HCPCS)    MAC    MAPC Measure
Hollister
INTERMITTENT CATHETERS, COUDÉ TIP, WITH ATTACHED COLLECTION BAGS
Advance Plus Pre-Lubricated Intermittent Catheter     95124 UK 10610075102027                           A4352     $3.45   $3.45     ea
With Introducer Tip and Urine Bag - Coude, 12 Fr, 16"
Advance Plus Pre-Lubricated Intermittent Catheter     95144 UK 10610075102034                           A4352     $3.45   $3.45     ea
With Introducer Tip and Urine Bag - Coude, 14 Fr, 16"
Advance Plus Pre-Lubricated Intermittent Catheter     95164 UK 10610075102041                           A4352     $3.45   $3.45     ea
With Introducer Tip and Urine Bag - Coude, 16 Fr, 16"
Pre-Lubricated 12 Fr Coudé Catheter w/ Collection     B12C  UP 187168000070                             A4352     $3.45   $3.45     ea
Bag
                                                            UK 20187168100071                           A4352     $3.45   $3.45     ea
                                                            UK 20610075177213                           A4352     $3.45   $3.45    ea *
Pre-Lubricated 14 Fr Coudé Catheter w/ Collection     B14C  UP 187168000155                             A4352     $3.45   $3.45     ea
Bag
                                                            UK 20187168100156                           A4352     $3.45   $3.45     ea
                                                            UK 20610075177299                           A4352     $3.45   $3.45    ea *
Pre-Lubricated 16 Fr Coudé Catheter w/ Collection     B16C  UP 187168000261                             A4352     $3.45   $3.45     ea
Bag
                                                            UK 20187168100262                           A4352     $3.45   $3.45     ea
                                                            UK 20610075177374                           A4352     $3.45   $3.45    ea *




*    Effective October 1, 2011

2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                September 2011
                                                                                                                                  mc sup prod uro int g
                                                                                                                                                      21
                                                                     Item Number                        Billing
                                                                     (reference         UPN             Code                    Unit of
Description                                                          only)              Qualifier UPN   (HCPCS)    MAC    MAPC Measure
MediCath
INTERMITTENT CATHETERS, STRAIGHT TIP, HYDROPHILIC, WITHOUT ATTACHED COLLECTION BAGS
  Hi-Slip Plus Male 16", 8 Fr              HS.PM4008    EN      8697749682738   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Male 16", 10 Fr             HS.PM4010    EN      8697749682745   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Male 16", 12 Fr             HS.PM4012    EN      8697749682752   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Male 16", 14 Fr             HS.PM4014    EN      8697749682707   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Male 16", 16 Fr             HS.PM4016    EN      8697749682714   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Male 16", 18 Fr             HS.PM4018    EN      8697749682769   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Male 16", 20 Fr             HS.PM4020    EN      8697749682998   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Male 16", 22 Fr             HS.PM4022    EN      8697749683001   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Male 16", 24 Fr             HS.PM4024    EN      8697749683018   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Pediatric 8", 6 Fr          HS.PP2006    EN      8697749682806   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Pediatric 8", 8 Fr          HS.PP2008    EN      8697749682813   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Pediatric 8", 10 Fr         HS.PP2010    EN      8697749682820   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Pediatric 12", 6 Fr         HS.PP3006    EN      8697749682837   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Pediatric 12", 8 Fr         HS.PP3008    EN      8697749682844   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Pediatric 12", 10 Fr        HS.PP3010    EN      8697749682851   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Female 8", 8 Fr             HS.PF2008    EN      8697749682776   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Female 8", 10 Fr            HS.PF2010    EN      8697749682783   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Female 8", 12 Fr            HS.PF2012    EN      8697749682691   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Female 8", 14 Fr            HS.PF2014    EN      8697749682721   A4351                             $2.40   $2.40         ea
  Hi-Slip Plus Female 8", 16 Fr            HS.PF2016    EN      8697749682790   A4351                             $2.40   $2.40         ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                   February 2012
mc sup prod uro int g
22

                                                                     Item Number                        Billing
                                                                     (reference         UPN             Code                    Unit of
Description                                                          only)              Qualifier UPN   (HCPCS)    MAC    MAPC Measure
MediCath
INTERMITTENT CATHETERS, STRAIGHT TIP, WITH ATTACHED COLLECTION BAGS
  Hi-Slip Kit, Male 16", 8 Fr               HS.KM4008   EN      8697749682271                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Male 16", 10 Fr              HS.KM4010   EN      8697749682288                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Male 16", 12 Fr              HS.KM4012   EN      8697749682295                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Male 16", 14 Fr              HS.KM4014   EN      8697749682301                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Male 16", 16 Fr              HS.KM4016   EN      8697749682318                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Pediatric 8", 6 Fr           HS.KP2006   EN      8697749682387                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Pediatric 8", 8 Fr           HS.KP2008   EN      8697749682394                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Pediatric 8", 10 Fr          HS.KP2010   EN      8697749682400                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Pediatric 12", 6 Fr          HS.KP3006   EN      8697749682417                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Pediatric 12", 8 Fr          HS.KP3008   EN      8697749682424                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Pediatric 12", 10 Fr         HS.KP3010   EN      8697749682431                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Female 8", 8 Fr              HS.KF2008   EN      8697749682332                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Female 8", 10 Fr             HS.KF2010   EN      8697749682349                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Female 8", 12 Fr             HS.KF2012   EN      8697749682356                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Female 8", 14 Fr             HS.KF2014   EN      8697749682363                           A4351     $3.45   $3.45     ea
  Hi-Slip Kit, Female 8", 16 Fr             HS.KF2016   EN      8697749682370                           A4351     $3.45   $3.45     ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                               September 2011
                                                                                                                                   mc sup prod uro int g
                                                                                                                                                     23

                                                                     Item Number                            Billing
                                                                     (reference  UPN                        Code                    Unit of
Description                                                          only)       Qualifier UPN              (HCPCS)    MAC    MAPC Measure
  Hi-Slip Full Plus Female, 8”, 8 Fr, Box/10                         HS.FPF2008 EN          8697749683032    A4351    $3.45   $3.45    ea
     Case/40                                                         HS.FPF2008 EN          8697749687504    A4351    $3.45   $3.45    ea
  Hi-Slip Full Plus Female, 8”, 10 Fr, Box/10                        HS.FPF2010 EN          8697749683049    A4351    $3.45   $3.45    ea
     Case/40                                                         HS.FPF2010 EN          8697749687511    A4351    $3.45   $3.45    ea
  Hi-Slip Full Plus Female, 8”, 12 Fr, Box/10                        HS.FPF2012 EN          8697749683056    A4351    $3.45   $3.45    ea
     Case/40                                                         HS.FPF2012 EN          8697749687528    A4351    $3.45   $3.45    ea
  Hi-Slip Full Plus Female, 8”, 14 Fr, Box/10                        HS.FPF2014 EN          8697749683063    A4351    $3.45   $3.45    ea
     Case/40                                                         HS.FPF2014 EN          8697749687535    A4351    $3.45   $3.45    ea
  Hi-Slip Full Plus Female, 8”, 16 Fr, Box/10                        HS.FPF2016 EN          8697749683070    A4351    $3.45   $3.45    ea
     Case/40                                                         HS.FPF2016 EN          8697749687542    A4351    $3.45   $3.45    ea
  Hi-Slip Full Plus Male, 16", 8 Fr , Box/10                         HS.FPM4008 EN          8697749683087    A4351    $3.45   $3.45    ea
     Case/40                                                         HS.FPM4008 EN          8697749687559    A4351    $3.45   $3.45    ea
  Hi-Slip Full Plus Male, 16", 10 Fr , Box/10                        HS.FPM4010 EN          8697749683094    A4351    $3.45   $3.45    ea
     Case/40                                                         HS.FPM4010 EN          8697749687566    A4351    $3.45   $3.45    ea
  Hi-Slip Full Plus Male, 16", 12 Fr , Box/10                        HS.FPM4012 EN          8697749683100    A4351    $3.45   $3.45    ea
      Case/40                                                        HS.FPM4012 EN          8697749687573    A4351    $3.45   $3.45    ea
  Hi-Slip Full Plus Male, 16", 14 Fr, Box/10                         HS.FPM4014 EN          8697749683117    A4351    $3.45   $3.45    ea
     Case/40                                                         HS.FPM4014 EN          8697749687580    A4351    $3.45   $3.45    ea
  Hi-Slip Full Plus Male, 16", 16 Fr, Box/10                         HS.FPM4016 EN          8697749683124    A4351    $3.45   $3.45    ea
     Case/40                                                         HS.FPM4016 EN          8697749687597    A4351    $3.45   $3.45    ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                 September 2011
mc sup prod uro int g
24

                                                                     Item Number                        Billing
                                                                     (reference         UPN             Code                    Unit of
Description                                                          only)              Qualifier UPN   (HCPCS)    MAC    MAPC Measure
MediCath
INTERMITTENT CATHETERS, COUDÉ TIP, HYDROPHILIC, WITHOUT ATTACHED COLLECTION BAGS
  Hi-Slip Plus Coudé 16", 10 Fr           HS.PT4010     EN     8697749685623   A4352                              $3.25   $3.25     ea
  Hi-Slip Plus Coudé 16", 12 Fr           HS.PT4012     EN     8697749685630   A4352                              $3.25   $3.25     ea
  Hi-Slip Plus Coudé 16", 14 Fr           HS.PT4014     EN     8697749685647   A4352                              $3.25   $3.25     ea
  Hi-Slip Plus Coudé 16", 16 Fr           HS.PT4016     EN     8697749685654   A4352                              $3.25   $3.25     ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                               September 2011
                                                                                                                                  mc sup prod uro int g
                                                                                                                                                       25

                                                                     Item Number                        Billing
                                                                     (reference         UPN             Code                    Unit of
Description                                                          only)              Qualifier UPN   (HCPCS)    MAC    MAPC Measure
Medical Technologies of Georgia (MTG)
INTERMITTENT CATHETERS, STRAIGHT TIP, WITH ATTACHED COLLECTION BAGS
MTG Kiddie-Kath, firm, 700 ml bag, 10", 8 Fr Mini-Pak, 30108 UP 892673002227                            A4351     $3.45   $3.45         ea
individual
   Case/100                                            30108 UK 10892673002224                          A4351     $3.45   $3.45         ea
MTG EZ-Advancer, firm, 700 ml bag, 10", 10 Fr          30110 UP 892673002265                            A4351     $3.45   $3.45         ea
Mini-Pak, individual
   Case/100                                            30110 UK 10892673002262                          A4351     $3.45   $3.45         ea
MTG Instant-Cath, firm, 1500 ml bag, 16", 12 Fr,       20112 UP 892673002005                            A4351     $3.45   $3.45         ea
individual
   Case/100                                            20112 UK 10892673002002                          A4351     $3.45   $3.45         ea
MTG EZ-Advancer, firm, 1500 ml bag, 16", 12 Fr,        30112 UP 892673002050                            A4351     $3.45   $3.45         ea
individual
   Case/100                                            30112 UK 10892673002057                          A4351     $3.45   $3.45         ea
MTG EZ-Advancer, soft, 1500 ml bag, 16", 12 Fr,        30212 UP 892673002326                            A4351     $3.45   $3.45         ea
individual
   Case/100                                            30212 UK 10892673002323                          A4351     $3.45   $3.45         ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                   September 2011
mc sup prod uro int g
26

                                                                     Item Number                                  Billing
                                                                     (reference         UPN                       Code                    Unit of
Description                                                          only)              Qualifier UPN             (HCPCS)    MAC    MAPC Measure
MTG Instant-Cath, firm, 1500 ml bag, 16", 14 Fr,                     20114               UP        892673002029    A4351    $3.45   $3.45    ea
individual
   Case/100                                                          20114               UK      10892673002026   A4351     $3.45   $3.45     ea
MTG EZ-Advancer, firm, 1500 ml bag, 16", 14 Fr,                      30114               UP      892673002098     A4351     $3.45   $3.45     ea
individual
   Case/100                                                          30114               UK      10892673002095   A4351     $3.45   $3.45     ea
MTG EZ-Advancer, soft, 1500 ml bag, 16", 14 Fr,                      30214               UP      892673002388     A4351     $3.45   $3.45     ea
individual
   Case/100                                                          30214               UK      10892673002385   A4351     $3.45   $3.45     ea
MTG Cath-Lean, firm, 700 ml bag, 6", 14 Fr Mini-Pak,                 40414               UP      892673002456     A4351     $3.45   $3.45     ea
individual
   Case/100                                                          40414               UK      10892673002453   A4351     $3.45   $3.45     ea
MTG Instant-Cath, firm, 1500 ml bag, 16", 16 Fr,                     20116               UP      892673002135     A4351     $3.45   $3.45     ea
individual
   Case/100                                                          20116               UK      10892673002132   A4351     $3.45   $3.45     ea
MTG-EZ Advancer, firm, 1500 ml bag, 16", 16 Fr,                      30116               UP      892673002166     A4351     $3.45   $3.45     ea
individual
   Case/100                                                          30116               UK      10892673002163   A4351     $3.45   $3.45     ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                         September 2011
                                                                                                                                  mc sup prod uro int g
                                                                                                                                                       27

                                                                     Item Number                        Billing
                                                                     (reference         UPN             Code                    Unit of
Description                                                          only)              Qualifier UPN   (HCPCS)    MAC    MAPC Measure
Medical Technologies of Georgia (MTG)
INTERMITTENT CATHETERS, COUDÉ TIP, WITH ATTACHED COLLECTION BAGS
MTG Instant-Cath, Coudé, 1500 ml bag, 16", 12 Fr, 20612 UP     892673002289                             A4352     $3.45   $3.45         ea
individual
   Case/100                                       20612 UK     10892673002286                           A4352     $3.45   $3.45         ea
MTG Instant-Cath, Coudé, 1500 ml bag, 16", 14 Fr, 20614 UP     892673002340                             A4352     $3.45   $3.45         ea
individual
   Case/100                                       20614 UK     10892673002347                           A4352     $3.45   $3.45         ea
MTG Instant-Cath, Coudé, 1500 ml bag, 16", 16 Fr, 20616 UP     892673002401                             A4352     $3.45   $3.45         ea
individual
   Case/100                                       20616 UK     10892673002408                           A4352     $3.45   $3.45         ea




2 – Medical Supply Products: Urologicals – Intermittent Catheters – Manufacturers G thru M                                                   September 2011

				
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