WOUND CARE SUPERBILL

Patient Name: Date of Service:
Date of Birth: Provider Name:
Visit Number:
Place of Service:
MAC Locality: Enter ZIP code above to auto-detect
Wound Number: Wound Location:
Wound Type: Duration:
Wound Size (LxW):
cm x cm = --cm2
Wound Depth:
cm
Products & Services
✓ Wound # Product / Service HCPCS / CPT Size Qty Used Units Billed Notes / ProPack Delivery Date
Grafts
 Tri-Membrane Wrap (per sq cm) Q4344
Membrane Wrap (per sq cm) Q4205
Membrane Wrap - Lite (per sq cm) Q4373
Microlyte SAM (per sq cm) A2005
ActiGraft+ (per application) G0465
Collagen Dressings
 Collagen Powder A6010
ProPack Delivery Date:
Collagen Dressing ≤16in2 A6021
ProPack Delivery Date:
Collagen Dressing >48in2 A6023
ProPack Delivery Date:
Secondary Dressings
 Alginate/Fiber Gelling ≤16in2 A6196
ProPack Delivery Date:
Alginate/Fiber Gelling >16≤48in2 A6197
ProPack Delivery Date:
Gauze, Non-Impreg. w/ border ≤16in2 A6219
ProPack Delivery Date:
Gauze, Non-Impreg. w/ border >16≤48in2 A6220
ProPack Delivery Date:
Hydrocolloid Dressing ≤16in2 A6237
ProPack Delivery Date:
Hydrocolloid Dressing >16≤48in2 A6238
ProPack Delivery Date:
Hydrocolloid Dressing >48in2 w/o border A6236
ProPack Delivery Date:
Specialty Absorptive >48in2 w/o border A6253
ProPack Delivery Date:
Securing Products
 Conforming Bandage, sterile, ≥3"<5", /yd A6446
ProPack Delivery Date:
Waterproof Tape A4452
ProPack Delivery Date:
Wound Vacs
 Disposable NPWT ≤50 sq cm (MicroDoc) 97607
Disposable NPWT >50 sq cm (MicroDoc) 97608
Traditional Wound Vac (DME) ≤50 sq cm 97605
Wound Vac Start Date:
Traditional Wound Vac (DME) >50 sq cm 97606
Wound Vac Start Date:
Frequency & Ordering
Dressing Change Freq: Next Patient Visit:
Provider Signature: Date:
Billing Summary
Product / Service HCPCS / CPT Units Billed Wound # Est. Reimb.
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I certify the above services were medically necessary and performed as documented. All information is accurate and complete.