Dressing Retention Rolls
Usual Allowable Amount: Based on frequency of change of wound cover; up to 2 units (36 sq. in.) per dressing change when wound cover is 16 sq. in. or less; up to 3 units (54 sq. in.) per dressing change when wound cover is 16 to 48 sq. in; up to 4 units (72 sq. in.) per dressing change when wound cover is greater than 48 sq. in.
Note: a unit is based on 1-in. wide tape
Specific Coverage Criteria: Covered when needed to hold on a wound cover, elastic roll gauze or non-elastic roll gauze; is not required when a wound cover with an adhesive border is used. The medical necessity for tape in these situations must be documented.
| Product # | Size | Rolls / Carton | HCPCS Code |
| 4209 | 2 x 10 yard roll | 24 | A4452 (per 18 sq in) |
| 4210 | 4 x 10 yard roll | 24 | A4452 (per 18 sq in) |
| 4211 | 6 x 10 yard roll | 24 | A4452 (per 18 sq in) |
| 4215 | 2 x 2 yard roll | 36 | A4452 (per 18 sq in) |
| 4216 | 4 x 2 yard roll | 18 | A4452 (per 18 sq in) |
| 4217 | 6 x 2 yard roll | 12 | A4452 (per 18 sq in) |
HYPAFIX™ is a Trademark of BSN Medical Limited.