HCPCS Level II › A codes A6204 Composite drsg >16<=48 sq inComposite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing
Medicare coverage: Special coverage instructions apply Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 0 units per day (clinical), rationale: CMS Policy Medicare pricing for A6204 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, surgical dressings (SD): non-rural $8.86 in the contiguous states; $8.86 to $10.62 in AK, HI, PR and VI; ceiling $8.86, floor $7.53 Physician Fee Schedule (CY 2026, RVU26D) Status P: bundled or excluded, no separate PFS payment.
Payer policies and prior authorization for A6204 Payer coverage policies that name A6204 A6204 appears in 2 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Dialysis (0541) covered if criteria are met (range A6010-A6457) Aug 26, 2026 payer document Aetna Surgical Devices, Dressings, and Wound Care Supplies (0526) covered if criteria are met (range A6203-A6205) Aug 26, 2026 payer document
Medicaid fee-for-service Prior authorization required or conditional in CO, KY, LA, MA, OH, VA, WV.
AZ: $10.57 (dme), effective Oct 1, 2026 CO: $6.09 (chp_plus, non-facility), effective Jul 1, 2026 FL: $5.11 (dme), effective Jul 1, 2026 IL: $5.93 (dme), effective Jan 1, 2026 IN: $7.39 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $7.09 (default), effective Jul 1, 2026 KY: $5.94 (dme), effective Jan 1, 2026 LA: $4.01 (dme), effective Sep 1, 2021 MA: $7.22 (dme_rates), effective Mar 1, 2026 MD: $7.53 (dme), effective Apr 1, 2026 MS: $7.09 (comprehensive), effective Jul 1, 2026 ND: $10.98 (dme), effective Aug 1, 2026 NE: $7.75 (dme), effective Jul 1, 2026 NY: $4.13 (dme), effective Jul 1, 2026 OH: $4.50 (dme), effective Jan 1, 1997 OK: $8.86 (dme), effective Jan 1, 2026 TX: $5.94 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Jul 1, 1997 VA: $7.97 (dme), effective Dec 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $6.67 (medical_equipment_supplies), effective Jul 1, 2026 WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026 From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.