medical supply products: tracheostomy – a thru f manufacturers
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mc sup prod trach a
Medical Supply Products: Tracheostomy – A thru F Manufacturers 1
This section lists the billing codes, manufacturer codes and units for tracheostomy supplies manufactured by companies with names that begin with the letters A-F. In this section “MAC” refers to maximum acquisition cost and “UPN” refers to the Universal Product Number. For additional help, refer to the Medical Supplies section in this manual. HCPCS codes are for reference only.
Treatment Authorization Requests (TARs) are issued only for products that exceed billing limitations, or where otherwise indicated. Miscellaneous procedure codes, such as 9999A or 9999C, may not be substituted.
MAC Guarantee Through The Department of Health Care Services (DHCS) negotiated a contract with a distributor, Independence Medical, toIndependence Medical Only establish maximum acquisition cost (MAC) agreements for tracheostomy products. The maximum acquisition cost listed
in the “MAC” column in this section reflects the guaranteed MAC only when providers buy tracheostomy products through Independence Medical. This price is not guaranteed if providers purchase directly from the manufacturer or another source. “Item” numbers listed in this section are Independence Medical item numbers.
Billing Instructions Claims submitted for contracted tracheostomy products must include both the billing code and either the UPN or item number. All attachments submitted with paper claims (invoice, catalog page or price list) must include the UPN or item number for the product being billed. If the UPN or item number is not pre-printed on the attachment, it should be handwritten on the attachment next to the supply for which it is required. If the UPN or item number is not included or is illegible the claim will be denied.
Computer Media Claims require the UPN or item number to be included in the Remarks field. All tracheostomy products must be billed to Medicare before being billing to Medi-Cal.
Effective Dates Tracheostomy products in this section are effective for dates of service on or after November 1, 2008, unlessotherwise noted.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
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Billing Limitations Tracheostomy supplies are limited to the following quantities without authorization.
Billing Code Limitation
9916L, 9916M, 9916S, 9916U, 9916W No more than 90 in an 81-day period
9916N, 9916Y, 9916Z No more than 6 in an 81-day period
9916P, 9916Q, 9917P, 9917Q, 9917V No more than 3 in an 81-day period
9916R, 9916V, 9916X No more than 1 unit per dispensing and 4 dispensings in a year
9916T No more than 12 in a 365-day period
9917S No more than 15 in an 81-day period
9917T No more than 12 in an 81-day period
9917U No more than 18 in an 81-day period
9981E, 9981J No more than 90 in an 81-day period
9981F No more than 360 in an 81-day period
Filter Holder and Claims submitted for medical supply code 9916X (filter holder and integrated filter housing, and adhesive, for use as heat Integrated Filter Housing: and moisture exchange system) must include documentation of product cost (invoice, manufacturer catalog page orMedical Supply Code 9916X price list), as an attachment to the claim. This is a non-contracted product. The quantity for code 9916X (HCPCS code
A7509) is limited to no more than one unit per dispensing and 4 dispensings in a year, without authorization.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers February 2009
Effective for Dates of Service On or Before March 31, 2009 Only
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TRACHEOSTOMY
DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Allegiance – 3J
Trach care kit w/hydrogen peroxide,case 30
553T4692C 50380470058776 A4625 9981E $2.23 each
Trach care kit w/hydrogen peroxide 553T4692 0038047005908 A4625 9981E $2.40 each
Trach care kit w/two compartment tray basin
553T4691AC 50380470058788 A4625 9981E $1.21 each
Basic trach care kit, non-sterile 553T4691A 100380470058825 A4625 9981E $1.21 each
Trach care kit in two compartment tray 553T4691 630140073963 A4625 9981E $1.67 each
Mini trach care kit 553T3030A 50380470058790 A4625 9981E $1.02 each
Trach mask, adult, w/6" flex tube 55001248 0055001248 A7525 9917T $4.10 each
Trach mask, adult 55001227 0055001227 A7525 9917T $1.22 each
Airlife trach mask, pediatric 55001226 630140015055 A7525 9917T $1.80 each
Trach mask, adult 55001225 630140015048 A7525 9917T $1.26 each
Suction cath kit, 14Fr 554114 380470035512 A4624 9981F $1.79 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Cath N Glove suction kit w/peel pouch, 5Fr 554660A 630140014768 A4624 9981F $0.77 kit
Cath N Glove suction kit w/peel pouch, 8Fr 554661A 500054661A A4624 9981F $0.65 kit
Cath N Glove suction kit w/peel pouch, 10Fr
554662A 630140014782 A4624 9981F $0.65 kit
Cath N Glove suction kit w/peel pouch, 14Fr
554664A 630140014799 A4624 9981F $0.65 each
Cath N Glove suction kit w/basin, 14Fr 554694T H1604694T5 A4624 9981F $0.51 each
Cath N Glove suction kit w/basin, 10Fr 554695T 50630140037304 A4624 9981F $0.61 each
Cath N Glove suction kit w/basin, 8Fr 554697T 630140037323 A4624 9981F $0.62 each
Cath N Glove catheter kit w/peel pouch, infant, 5/6Fr
554893T 000554893T A4624 9981F $0.53 each
Cath N Glove suction kit w/basin, 14Fr,100 sets per case
554894T 50630140143838 A4624 9981F $0.53 each
Suction Cath set w/gloves & basin, 10Fr 554895T 630140143857 A4624 9981F $0.54 each
Suction Cath set w/gloves & basin, 8Fr 554897T 630140143888 A4624 9981F $0.54 each
Cath N Glove suction kit w/peel pouch, 12Fr
554898T 50380470012303 A4624 9981F $0.53 each
Tri-Flo no touch suction catheter kit, 14Fr 55T160C 50630140030527 A4624 9981F $0.97 each
Tri-Flo no touch suction catheter kit, 10Fr 55T161C 630140030515 A4624 9981F $1.14 each
Tri-Flo no touch suction catheter kit w/control valve, 18Fr
55T162C 00055T162C A4624 9981F $1.06 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Suction Catheter w/o control valve, sterile, 14Fr
55T260 50630140263710 A4624 9981F $0.54 each
Tri-Flo straight-packed cath, 14Fr, 20" long 55T260C 630140263722 A4624 9981F $0.30 each
Control suction cath, straight-packed, 10Fr 55T261C 50630140263758 A4624 9981F $0.38 each
Tri-flo suction cath w/o cntrl port, 14Fr 55T60 630140026655 A4624 9981F $0.51 each
Tri-flo coil-packed cath, 14Fr, 20" long 55T60C H160T60C5V A4624 9981F $0.27 each
Tri-flo coil-packed cath, 10Fr, 20" long 55T61C H160T61C5W A4624 9981F $0.29 each
Tri-flo coil-packed cath, 18Fr, 20" long 55T62C 000055T62C A4624 9981F $0.40 each
Tri-flo coil-packed cath, 5/6Fr, 14" long 55T63C H160T63C5 A4624 9981F $0.36 each
Tri-flo suction cath w/o cntrl port, coil, pediatric, 8Fr
55T64 0000055T64 A4624 9981F $0.41 each
Tri-flo coil-packed cath, 8Fr, 15" long 55T64C H160T64C5 A4624 9981F $0.29 each
Decanulation plug, cap for trach, red 55MZ6DCP 000055MZ6DCP A7527 9917V $9.14 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Bard – BA
8Fr Trach Suction Cath'n Sleeve Kit 570089080 H30200890801 A4624 9981F $2.25 each
10Fr Trach Suction Cath'n Sleeve Kit 570089100 H30200891003 A4624 9981F $2.25 each
14Fr Trach Suction Cath'n Sleeve Kit 570089140 H30200891400 A4624 9981F $2.25 each
18Fr (22") Catheter Kit w/cath'n sleeve device, single use
570089180 H30200891800 A4624 9981F $2.25 each
10Fr (22") Catheter Kit w/cath'n sleeve device, single use
570089300 H30200893000 A4624 9981F $2.40 each
14Fr (22") Catheter Kit w/cath'n sleeve device, single use
570089340 H30200893400 A4624 9981F $2.40 each
14-16Fr (16") Rubber bronchial coude catheter w/funnel end, x-ray opaque, one eye, whistle tip, single use
570107150 H30201071500 A4624 9981F $2.01 each
10-12Fr (16") Rubber suction catheter w/funnel end, x-ray opaque, two eyes, whistle tip, single use
570108100 H30201081000 A4624 9981F $1.66 each
14-16Fr (16") Rubber suction catheter w/funnel end, x-ray opaque, two eyes, whistle tip, single use
571018150 H30201081502 A4624 9981F $1.66 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
17-19Fr (16") Rubber suction catheter w/funnel end, x-ray opaque, two eyes whistle tip, single use
570108190 H30201081900 A4624 9981F $1.66 each
10-12Fr Rubber bronchial coude catheter, x-ray opaque, one eye, whistle tip, thumb valve
570109120 H30200109120 A4624 9981F $2.12 each
14-16Fr Rubber bronchial coude catheter, x-ray opaque, one eye, whistle tip, thumb valve
570109150 H30201091500 A4624 9981F $2.12 each
17-19Fr Rubber bronchial coude catheter, x-ray opaque, one eye, whistle tip, thumb valve
570109190 H30201091900 A4624 9981F $2.12 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
8Fr (18") Rubber suction catheter w/thumb valve, x-ray opaque, whistle tip, two eyes
570128080 H30201280800 A4624 9981F $1.86 each
10-12Fr (18") Rubber suction catheter w/thumb valve, x-ray opaque, whistle tip, two eyes
570128100 H30201281000 A4624 9981F $1.86 each
14-16Fr (18") Rubber suction catheter w/thumb valve, x-ray opaque, whistle tip, two eyes
570128150 H30201281500 A4624 9981F $1.86 each
17-19Fr (18") Rubber suction catheter w/thumb valve, x-ray opaque, whistle tip, two eyes
570128190 H30201281900 A4624 9981F $1.86 each
10-12Fr (18") Rubber catheter kit w/pop-up solution container
570140000 H30201400000 A4624 9981F $2.31 each
14-16Fr Tracheal suction latex catheter & glove kit, w/rubber whistle-tip cath, thumb valve, two side eyes
570140020 H30201400200 A4624 9981F $2.31 each
17-19Fr (18") Rubber catheter kit w/pop-up solution container
570140030 H30201400300 A4624 9981F $2.31 each
10Fr (22") Whistle tip catheter kit, w/two eyes, control vent
570140040 H30201400404 A4624 9981F $1.36 each
14Fr (22") Whistle tip catheter kit, w/two eyes, control vent
570140050 H303140054 A4624 9981F $1.36 each
18Fr (22") Whistle tip catheter kit, w/two eyes, control vent
570140060 H30201400601 A4624 9981F $1.36 each
5Fr (16") Whistle tip catheter kit w/1cm depth markings, two eyes, control vent
570140070 H30201400700 A4624 9981F $1.36 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
8Fr (16") Whistle tip catheter kit w/1cm depth markings, two eyes, control vent
570140080 H30201400800 A4624 9981F $1.36 each
10-12Fr (18") Rubber bronchial catheter kit w/ thumb valve, one eye, coude whistle tip
570140090 H30201400900 A4624 9981F $2.54 each
14-16Fr (18") Rubber bronchial catheter kit w/ thumb valve, one eye, coude whistle tip
570140100 H30201401000 A4624 9981F $2.54 each
8Fr (16") Suction catheter w/1cm depth markings, thumb valve, two eyes, whistle tip
570360080 H30203600800 A4624 9981F $1.31 each
10Fr (22") Suction catheter w/thumb valve, two eyes, whistle tip
570360100 H30203601000 A4624 9981F $1.31 each
14Fr (22") Suction catheter w/thumb valve, two eyes, whistle tip
570360140 H30203601400 A4624 9981F $1.31 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Bivona – 3F
Custom trach w/hyperflex shaft w/aircuff,6 mm ID, 95 mm length
BJTRACHSP4 BJTRACHSP4 A7521 9916Z $320.65 each
Sleep Apnea Tracheostomy tube, 7.5 mm ID, 11.0 mm OD, 79 mm length
BJSAT757 05021312010926 A7520 9916Y $71.69 each
Sleep Apnea Tracheostomy tube, 73 mm length
BJSAT656 05021312010919 A7520 9916Y $71.69 each
Sleep Apnea Trach tube, 6.0 mm ID,9.0 mm OD, 68.0 mm length
BJSAT605 05021312010902 A7520 9916Y $75.02 each
Bivona trach vent, 16Fr, 55 mm long,10.5 mm ID, 24 mm OD
BJBV1655 05021312010001 A7520 9916Y $82.28 each
Tracheostoma vent, size 12, 13.5 ID,17.0 OD, 55 mm long
BJBV1255 05021312009920 A7520 9916Y $82.28 each
Tracheostoma vent, 12.0 mm ID, 15 mm OD, 55 mm long
BJBV1055 05021312009883 A7520 9916Y $82.28 each
Tracheostoma vent, size 10, 12 mm ID,15 mm OD, 36 mm long
BJBV1036 05021312009876 A7520 9916Y $77.44 each
Tracheostoma vent, size 9, 10.5 mm ID, 13.5 mm OD, 55 mm long
BJBV0955 05021312009838 A7520 9916Y $77.44 each
Tracheostoma vent, size 9, 10.5 mm ID, 13.5 mm OD, 36 mm long
BJBV0936 05021312009821 A7520 9916Y $77.44 each
Tracheostoma vent, size 9, 10.5 mm ID, 13.5 mm OD, 27.0 mm long
BJBV0927 05021312009814 A7520 9916Y $77.44 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Tracheostoma vent, size 8, 9.5 mm ID,12 mm OD, 55 mm long
BJBV0855 05021312009791 A7520 9916Y $77.44 each
Tracheostoma vent, size 8, 9.5 mm ID, 12 mm OD, 36 mm long
BJBV0836 05021312009784 A7520 9916Y $77.44 each
Bivona laryngectomy tube, short, 11.0 mm ID, 14 mm OD, 55 mm length
BJBOSL3S 05021312008848 A7520 9916Y $113.74 each
Laryngectomy tube, short, 9.5 mm ID,12 mm OD, shaft length 55
BJBOSK1S 05021312008824 A7520 9916Y $113.74 each
Fome-Cuf pediatric silicone tracheostomy tube, 5.0 mm ID, 7.3 mm OD, 44.0 mm length
BJ85P050 05021312007032 A7521 9916Z $226.27 each
Fome-Cuf pediatric trach tube, 4.0 mm ID, 6.0 mm OD, 41.0 mm length, Silicone
BJ85P040 05021312007018 A7521 9916Z $226.27 each
Fome-Cuf adult trach tube kit w/sideport, autocontrol airway connector & CMD,9.5 mm ID, 13.3 mm OD, 98 mm length
BJ850195 05021312006813 A7521 9916Z $115.82 each
Fome-Cuf adult trach tube kit w/sideport, autocontrol airway connector & CMD,9.0 mm ID, 12.3 mm OD, 98 mm length
BJ850190 050213120006806 A7521 9916Z $115.82 each
Fome-Cuf adult trach tube kit w/sideport, autocontrol airway connector & CMD,8.0 mm ID
BJ850180 050213120006790 A7521 9916Z $115.82 each
Fome-Cuf adult trach tube kit w/sideport, autocontrol airway connector & CMD,7.0 mm ID, 10 mm OD, 80 mm length
BJ850170 05021312006783 A7521 9916Z $115.82 each
Fome-Cuf adult trach tube kit w/sideport, autocontrol airway connector & CMD,6.0 mm ID, 8.7 mm OD, 70 mm length
BJ850160 05021312006776 A7521 9916Z $115.82 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Hyperflex trach tube, fixed 8 mm, cuffed,x-long
BJ75FHXL80 05021312015693 A7521 9916Z $114.95 each
Hyperflex trach tube, fixed 6 mm, cuffed,x-long
BJ75FHXL60 05021312015679 A7521 9916Z $114.95 each
Mid-Range with Aire-cuf trach tube, 9.0 BJ750190 05021312006431 A7521 9916Z $88.33 each
Mid-Range with Aire-Cuf trach tube, 8.0 BJ750180 05021312006424 A7521 9916Z $88.33 each
Mid-Range with Aire-Cuf trach tube, 7.0 BJ750170 05021312006417 A7521 9916Z $88.33 each
Mid-Range with Aire-Cuf trach tube, 6.0 BJ750160 05021312006394 A7521 9916Z $88.33 each
Mid-Range with Aire-Cuf trach tube, 5.0 BJ750150 05021312006400 A7521 9916Z $88.33 each
Pediatric trach tube, cuffed, tight to shaft, 5.5 mm ID, 46 mm length
BJ67P055 05021312006301 A7521 9916Z $208.64 each
Pediatric trach tube, tight to shaft, silicone wire reinforced tube, 5.0 mm ID, 7.3 mm OD, 44 mm length
BJ67P050 05021312006295 A7521 9916Z $215.10 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Pediatric trach tube, tight to shaft, 4.5 mm ID, 42 mm length
BJ67P045 05021312006288 A7521 9916Z $208.64 each
Pediatric trach tube, tight to shaft, 4.0 mm ID, 41 mm length
BJ67P040 05021312006271 A7521 9916Z $208.64 each
Pediatric trach tube, Aire-Cuf, tight to shaft, 3.5 mm ID, 5.3 mm OD, 16Fr
BJ67P035 05021312006264 A7521 9916Z $215.10 each
Pediatric trach tube, Aire-Cuf, tight to shaft, 3.0 mm ID
BJ67P030 05021312006257 A7521 9916Z $215.10 each
Hyperflex adult tracheostomy tube w/fixed neck flange, 6.0 mm ID, 8.6 mm OD,70 mm length
BJ67FH60 05021312013750 A7520 9916Y $104.80 each
Trach tube, tight to shaft, cuffed, 9.8 mm ID, 98 mm long
BJ670195 05021312006103 A7521 9916Z $88.25 each
Trach tube, tight to shaft, cuffed, nonfenestrated, size 9, 98 mm length
BJ670190 05021312006097 A7521 9916Z $88.25 each
Trach tube, tight to shaft, cuffed,nonfenestrated, 8.5 mm ID
BJ670185 05021312006080 A7521 9916Z $88.25 each
Trach tube, tight to shaft, adult, cuffed, nonfenestrated, 8 mm ID, 11 mm OD,88 mm length
BJ670180 05021312006073 A7521 9916Z $85.91 each
Trach tube, tight to shaft, adult, cuffed, nonfenestrated, 7.55 mm ID, 10.4 mm OD, 80 mm length
BJ670175 05021312006066 A7521 9916Z $88.25 each
Adult trach tube, cuffed, nonfenestrated, no inner cannula, 7.0
BJ670170 05021312006059 A7521 9916Z $88.25 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Trach tube, tight to shaft, cuffed, nonfenestrated, 6.5 mm ID, 9.4 mm OD,70 mm length
BJ670165 05021312006042 A7521 9916Z $88.25 each
Trach tube, tight to shaft, cuffed, no inner cannula, 6 mm
BJ670160 05021312006035 A7521 9916Z $85.91 each
Trach tube, tight to shaft, cuffed, non fenestrated, 5.0 mm ID, 7.3 mm OD,60 mm length
BJ670150 05021312006028 A7521 9916Z $85.60 each
Pediatric trach tube, Aire-Cuf, 5.5 mm ID, 46 mm long
BJ65P055 05021312006004 A7521 9916Z $242.00 each
Pediatric trach tube, Aire-Cuf, 5.0 mm ID, 7.3 mm OD, 44 mm long
BJ65P050 05021312005991 A7521 9916Z $229.90 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Pediatric trach tube, 4.5 mm ID, 6.7 mm OD, 42 mm long
05021312005984 A7521 9916Z $226.12 each
Pediatric trach tube, Aire-Cuf, 4.0 mm ID, 41 mm long
05021312005977 A7521 9916Z $226.12 each
Pediatric trach tube, Aire-Cuf, 3.5 mm ID, 5.3 mm OD, 40 mm long
BJ65P035 050251312005960 A7521 9916Z $226.12 each
Neonatal trach tube, 2.5 mm ID BJ65N025 05021312005908 A7520 9916Y $226.12 each
Flextend Plus Standard Pediatric trach tube, 5.5 mm ID, 8.0 mm OD, 46 mm length
BJ60PFS55 05021312005892 A7520 9916Y $95.59 each
Flextend Plus Standard Pediatric trach tube, 5.0 mm ID, 7.3 mm OD, 44 mm length
BJ60PFS50 05021312005885 A7520 9916Y $95.59 each
Flextend Pediatric trach tube, 4.5 ID,6.7 OD, 42 mm distal shaft length, 30 mm proximal shaft
BJ60PFS45 05021312005878 A7520 9916Y $95.59 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
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DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Flextend Plus Standard Pediatric trach tube, 4.0 mm ID, 6.0 mm OD, 41 mm distal shaft length, 25 mm proximal shaft length
BJ60PFS40 05021312005861 A7520 9916Y $94.16 each
Flextend Pediatric trach tube, 3.5 mm ID, 5.3 mm OD, 40 mm length
BJ60PFS35 05021312005854 A7520 9916Y $95.59 each
Flextend Pediatric trach tube, 3.0 mm ID, 4.7 mm OD, 10 mm Flextend length
BJ60PFS30 05021312005847 A7520 9916Y $95.59 each
Flextend Pediatric trach tube, 2.5 mm ID, 4.0 mm OD, 10 mm Flextend length
BJ60PFS25 05021312005830 A7520 9916Y $95.59 each
Flextend Plus Pediatric trach tube, 5.5 mm ID, 8.0 mm OD, 52 mm length
BJ60PFP55 05021312014757 A7520 9916Y $178.70 each
Flextend Plus Pediatric trach tube, 5.0 mm ID, 7.3 mm OD, 50 mm length
BJ60PFP50 05021312005823 A7520 9916Y $178.70 each
Flextend Plus Pediatric trach tube, 4.5 mm ID, 6.7 mm OD, 48 mm length
BJ60PFP45 05021312005816 A7520 9916Y $178.70 each
Flextend Pediatric trach tube, 4.0 mm ID, 6.0 mm OD, 41 mm length
BJ60PFP40 05021312005809 A7520 9916Y $178.70 each
Flextend Plus Pediatric trach tube, 3.5 mm OD, 4.3 mm OD, 40 mm length
BJ60PFP35 05021312005793 A7520 9916Y $178.70 each
Pediatric trach tube, cuffless 5.5 mm OD, 46 mm long
BJ60P055 05021312005786 A7520 9916Y $43.56 each
Pediatric trach tube, cuffless, size 5.0 BJ60P050 05021312005779 A7520 9916Y $43.56 each
Pediatric trach tube, cuffless 6.7 mm OD, 4.5 mm ID
BJ60P045 05021312005762 A7520 9916Y $43.56 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
17
DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Pediatric trach tube, cuffless 4 mm ID,6.0 mm OD
BJ60P040 05021312005755 A7520 9916Y $43.56 each
Pediatric trach tube, cuffless 3.5 mm ID, 5.3 mm OD
BJ60P035 05021312005748 A7520 9916Y $43.56 each
Pediatric trach tube, cuffless 3.0 mm ID, 4.7 mm OD
BJ60P030 05021312005731 A7520 9916Y $43.56 each
Pediatric trach tube, cuffless 2.5 mm ID, 4.0 mm OD, 38 mm length
BJ60P025 05021312005724 A7520 9916Y $67.29 each
Flextend neonatal trach tube, 4.0 mm ID, 6.0 mm OD
BJ60NFP40 05021312014740 A7520 9916Y $178.70 each
Flextend Plus neonatal trach tube, size 3.5 BJ60NFP35 05021312014733 A7520 9916Y $173.33 each
Flextend Plus neonatal trach tube, uncuffed, 3.0 mm ID, 4.7 mm OD, 32.00 mm distal length, 17.0 mm proximal length
BJ60NFP30 05021312014726 A7520 9916Y $173.33 each
Neonatal Trach tube, 4.0 mm ID, 36 mm long
BJ60N040 05021312005717 A7520 9916Y $43.56 each
Neonatal trach tube, cuffless, 3.5 mm ID, 34 mm long
BJ60N035 05021312005700 A7520 9916Y $43.56 each
Neonatal trach tube, cuffless, 3.0 mm ID, 4.7 mm OD, 32 mm long
BJ60N030 05021312005694 A7520 9916Y $43.56 each
Neonatal trach tube, cuffless, 2.5 mm ID, 30 mm long
BJ60N025 05021312005687 A7520 9916Y $67.29 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
18
DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Hyperflex fixed flange, x-large uncuffed trach tube, 7.0 mm
BJ60AFHXL70 05021312005648 A7520 9916Y $114.95 each
Hyperflex fixed-flange, extra length trach tube, 6.0 mm ID, 8.7 OD, 100.0 mm long
BJ60AFHXL60 05021312015631 A7520 9916Y $114.95 each
Adult trach tube, cuffless, all silicone,9.0 mm ID, 12.3 mm OD, 98 mm length
BJ60A190 05021312005588 A7520 9916Y $43.56 each
Adult trach tube, cuffless, all silicone,8.0 mm ID, 11.0 mm OD, 88 mm length
BJ60A180 05021312005571 A7520 9916Y $43.56 each
Adult trach tube, cuffless, all silicone,7.0 mm ID, 10.0 mm OD, 80 mm length
BJ60A170 05021312005564 A7520 9916Y $43.56 each
Adult trach tube, cuffless, all silicone,6.0 mm ID
BJ60A160 5021312005557 A7520 9916Y $43.56 each
Adult trach tube, cuffless, all silicone,5.0 mm ID, 7.33 mm OD, 60 mm length
BJ60A150 5021312005540 A7520 9916Y $43.56 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
19
DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Boston Medical – 4B
Singer Laryngectomy tube, size12 x 55 mm
BHSLT1255 0BHSLT1255 A7520 9916Y $72.60 each
Singer Laryngectomy tube, size11 x 36 mm
BHSLT1136 0BHSLT1136 A7520 9916Y $72.60 each
Singer Laryngectomy tube, size11 x 27 mm
BHSLT1127 0BHSLT1127 A7520 9916Y $72.60 each
Singer Laryngectomy tube, size10 x 55 mm
BHSLT1055 0BHSLT1055 A7520 9916Y $72.60 each
Singer laryngectomy tube, size 10 x 27 mm BHSLT1027 0BHSLT1027 A7520 9916Y $72.60 each
Singer laryngectomy tube, size 9 x 55 mm BHSLT0955 0BHSLT0955 A7520 9916Y $72.60 each
Singer laryngectomy tube, size 9 x 36 mm BHSLT0936 0BHSLT0936 A7520 9916Y $72.60 each
Singer laryngectomy tube, size 9 x 27 mm BHSLT0927 0BHSLT0927 A7520 9916Y $72.60 each
Singer laryngectomy tube, size 8 x 55 mm BHSLT0855 0BHSLT0855 A7520 9916Y $72.60 each
Singer laryngectomy tube, size 8 x 27 mm BHSLT0827 0BHSLT0827 A7520 9916Y $72.60 each
Moore trach tube, extra-long standard length, size 8
BHMTT008 0BHMTT008 A7520 9916Y $187.55 each
Moore trach tube, extra-long standard length, size 6
BHMTT006 0BHMTT006 A7520 9916Y $187.55 each
Safe-t-tube Montgomery, standard, 12 mm, clear trach tube
BH420012 00BH420012 A7520 9916Y $193.60 each
Safe-t-tube Montgomery, standard, 10 mm, clear trach tube
BH420010 00BH420010 A7520 9916Y $193.60 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
20
DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Montgomery long term cannula set, size 10, fits stoma 49-57 mm long
BH331057 00BH331057 A7520 9916Y $127.05 each
Montgomery long term cannula set, size 10, fits stoma 33-41 mm long
BH331041 00BH331041 A7520 9916Y $127.05 each
Montgomery long term cannula set, size 10, fits stoma 25-33 mm long
BH331033 00BH331033 A7520 9916Y $127.05 each
Montgomery long term cannula set, size 10, fits stoma 17-25 mm long
BH331025 00BH331025 A7520 9916Y $127.05 each
Montgomery long term cannula set, size 8, fits stoma 41-49 mm long
BH330849 00BH330849 A7520 9916Y $127.05 each
Montgomery long term cannula set, size 8 fits stoma 25-33 mm long
BH330833 00BH330833 A7520 9916Y $127.05 each
Montgomery long term cannula set, size 8, fits stoma 17-25 mm long
BH330825 00BH330825 A7520 9916Y $127.05 each
Montgomery long term cannula set, size 6, fits stoma 57-65 mm long
BH330665 00BH330665 A7520 9916Y $127.05 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
21
DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Montgomery long term cannula set, size 6, fits stoma 41-49 mm long
BH330649 00BH330649 A7520 9916Y $127.05 each
Montgomery long term cannula set, size 6, fits stoma 25-33 mm long
BH330633 00BH330633 A7520 9916Y $127.05 each
Montgomery long term cannula set, size 6, fits stoma 17-25 mm long
BH330625 00BH330625 A7520 9916Y $127.05 each
Montgomery short term cannula set, size 6 BH330601 00BH330601 A7520 9916Y $114.95 each
Montgomery long term cannula set, size 4, fits stoma 17-25 mm long
BH330425 00BH330425 A7520 9916Y $127.05 each
Tracoe twist cuffless trach tube system, size 6
BH30306 00BH30306 A7520 9916Y $66.55 each
Tracoe comfort trach tube system, size 9 BH2059 0000BH2059 A7520 9916Y $306.13 each
Tracoe comfort trach tube system, size 8 BH20508 000BH20508 A7520 9916Y $306.13 each
Tracoe comfort trach tube system,extra-long length w/low profile inner cannula, size 7
BH20207 000BH20207 A7520 9916Y $234.74 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
mc sup prod trach a
22
DescriptionItemNumber UPN
HCPCS (reference only)
BillingCode MAC
Unit ofMeasure
Tracoe comfort trach tube system,extra-long length w/low profile inner cannula, size 6
BH20206 000BH20206 A7520 9916Y $234.74 each
Tracoe comfort trach tube system,extra-long length w/o inner cannula, size 5
BH20105 000BH20105 A7520 9916Y $152.46 each
Tracoe comfort trach tube system, standard length w/ 15 mm poly adapter, size 7
BH10507 000BH10507 A7520 9916Y $227.48 each
Tracoe comfort trach tube system, standard length w/ 15 mm poly adapter, size 6
BH10506 000BH10506 A7520 9916Y $227.48 each
Tracoe trach tube one swivel valve, size 12 BH10412 000BH10412 A7520 9916Y $337.59 each
Tracoe trach tube, standard w/swivel valve, non-fenes, size 7
BH10407NF 0BH10407NF A7520 9916Y $337.59 each
Tracoe trach tube one swivel valve, size 7 BH10407 000BH10407 A7520 9916Y $337.59 each
Tracoe trach tube one swivel valve, size 6 BH10406 000BH10406 A7520 9916Y $337.59 each
Tracoe trach tube w/silver speaking valve, size 8
BH10308 000BH10308 A7520 9916Y $494.89 each
Dale Medical – 2Y
Trach tube holder extension (attachment for 240)
DA243 DA243 A7526 9917U $1.45 each
Trach tube holder for neonate - infant DA242 H84102421 A7526 9917U $2.54 each
Trach neckband, two-piece padded w/stretch panel, 1" wide band
DA240 H84102401 A7526 9917U $2.78 each
Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.
2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers October 2008
Effective for Dates of Service On or Before March 31, 2009 Only
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