| HCPCS Code: |
A6404 |
| Long Description: |
Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing |
| Short Description: |
Sterile gauze > 48 sq in |
| Pricing Indicator 1: |
35 (Surgical dressings (price subject to floors and ceilings)) |
| Multiple Pricing Code: |
A (Not applicable as HCPCS priced under one methodology) |
| MCM Reference Section Number 1: |
2079 |
| Statute Number: |
|
| Coverage Code: |
D (Special coverage instructions apply) |
| ASC Payment Group Code: |
|
| Processing Note Number: |
|
| Berenson-Eggers Type of Service (BETOS) Code: |
D1A (Medical/surgical supplies) |
| Type of Service Code 1: |
S (Surgical dressings or other medical supplies (effective 04/95)) |
| Anesthesia Base Unit Quality: |
0 |
| Code Added: |
01-01-1997 |
| Action Effective Date: |
01-01-2003 |
| Action Code: |
N (No maintenance for this code) |
