Local Coverage Article

Tracheostomy Care Supplies - Policy Article

A52492

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
CGS Administrators, LLC	DME MAC	17013 - DME MAC	J-B	Illinois Indiana Kentucky Michigan Minnesota Ohio Wisconsin
CGS Administrators, LLC	DME MAC	18003 - DME MAC	J-C	Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi New Mexico North Carolina Oklahoma Puerto Rico South Carolina Tennessee Texas Virgin Islands Virginia West Virginia
Noridian Healthcare Solutions, LLC	DME MAC	16013 - DME MAC	J-A	Connecticut Delaware District of Columbia Maine Maryland Massachusetts New Hampshire New Jersey New York - Entire State Pennsylvania Rhode Island Vermont
Noridian Healthcare Solutions, LLC	DME MAC	19003 - DME MAC	J-D	Alaska American Samoa Arizona California - Entire State Guam Hawaii Idaho Iowa Kansas Missouri - Entire State Montana Nebraska Nevada North Dakota Northern Mariana Islands Oregon South Dakota Utah Washington Wyoming

Article Information

General Information

Article ID
A52492

Article Title
Tracheostomy Care Supplies - Policy Article

Article Type
Article

Original Effective Date
10/01/2015

Revision Effective Date
01/01/2020

Revision Ending Date
N/A

Retirement Date
N/A

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Article Guidance

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).

Tracheostomy Supplies are covered under the Prosthetic Benefit (Social Security Act §1861(s)(8)). In order for a beneficiary’s supplies to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

Supplies for care of a tracheostomy site are covered for a beneficiary following an open surgical tracheostomy which has been open or is expected to remain open for at least three months. The quantities of supplies included in a tracheostomy care kit are to provide all necessary quantities for the care of the tracheostomy site and there must not be any additional quantity billed of these codes for this purpose. Additional supplies may be billed, as appropriate and necessary, only for care other than for a tracheostomy site, such as for speaking valves.

Claims for tape (A4450 or A4452) or for wipes or swabs (A5120) that are billed without an AU modifier will be rejected as missing information.

REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.

The diagnosis code that justifies the need for these items must be included on each claim.

CODING GUIDELINES

A tracheostomy care or cleaning starter kit (A4625) contains the following:

Item	Number included
plastic tray	1
basin	1
sterile gloves	1 pair
tube brush	1
pipe cleaners	3
pre-cut tracheostomy dressing	1
gauze	1 roll
4x4 sponges	4
cotton tip applicators	2
twill tape	30 inches

A tracheostomy care kit for an established tracheostomy (A4629) contains the following:

Item	Number included
tube brush	1
pipe cleaners	2
cotton tip applicators	2
twill tape	30 inches
4x4 sponges	2

A Column II code is included in the allowance for the corresponding Column I code when provided at the same time.

Column I	Column II
A4625	A4626
A4629	A4626

Tracheostomy care kits provided in the first two postoperative weeks should be coded as A4625.

Tracheostomy care kits provided after the first two postoperative weeks should be coded as A4629.

When codes A4450, A4452 and A5120 are used with Tracheostomy Care Supplies, they must be billed with the AU modifier. For this policy, codes A4450, A4452 and A5120 are the only codes for which the AU modifier may be used.

A7526 is a tracheostomy collar/holder that is used to secure the tracheostomy tube's positioning, minimize movement of the tracheostomy tube and reduce the risk of cannula disruption or decannulation. Fastener tabs attach to the tracheostomy tube to hold the collar in place. A7526 should not be used for billing twill ties, or twill tape or equivalent fabric or plastic supplies.

Heat/Moisture Exchangers

Heat/Moisture Exchangers (HME; see below for specific component codes) are a type of stoma cover which help laryngectomees partially restore functions previously performed by the nose and upper airway. During exhalation, warmth and humidity are conveyed from the lungs and deposited into the filter. During inhalation, the warmth and moisture are picked back up by incoming air and returned to the lungs.

HME consist of a plastic cassette/holder that contains a filter. The holder fits into a plastic housing which is held in place over the tracheostoma by adhesive. An HME may be used by itself or in addition to a tracheostoma valve (A7501).

A4481 is a small filter usually having adhesive along one edge which is attached to the skin and simply covers the tracheostoma to keep large piece of debris out. It is not an HME.

A4483 is a moisture exchanger that is used only with an invasive mechanical ventilator and should not be billed as an HME over a tracheostoma.

A7503 is a device that connects to the tracheostoma cassette and holds an HME filter. The holder/cap can open and close to replace the HME filter.

A7504 is a filter that fits into A7503.

A7506 is a double sided adhesive disc that attaches the HME cassette to the beneficiary’s skin.

A7507 is an integrated filter and holder that utilizes A7506 to fit over the tracheostomy or may utilize liquid adhesive on both sides of the cassette to attach the HME to the beneficiary.

A7508 is integrated housing and adhesive used with either an HME or tracheostoma valve.

A7509 is the integrated filter holder and housing used with the HME system.

A tracheostomy valve with diaphragm (A7501) is a device used over the tracheostomy stoma by a beneficiary who has had the larynx removed and has a tracheo-esophageal voice prosthesis, but does not have a tracheostomy tube.

Tracheostomy tubes (A7520, A7521, A7522) are all-inclusive. All variations in tracheostomy tube construction such as dimensions, materials, cuffs, connectors etc., including all variations often classified by manufacturers as “customized” are included in HCPCS codes A7520, A7521, and A7522.

Miscellaneous or NOC (not otherwise classified) codes such as E1399 (DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS) or A9999 (MISCELLANEOUS DME SUPPLY OR ACCESSORY, NOT OTHERWISE SPECIFIED) must not be used to bill Medicare for any tracheostomy tube. Use of a miscellaneous code to bill Medicare for any tracheostomy tubes is incorrect coding.

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.

Coding Information

CPT/HCPCS Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(8 Codes)

Group 1 Paragraph

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the Article Text field, Non-Medical Necessity Coverage and Payment Rules section for other coverage criteria and payment information.

Group 1 Codes

Code	Description
J95.00	Unspecified tracheostomy complication
J95.01	Hemorrhage from tracheostomy stoma
J95.02	Infection of tracheostomy stoma
J95.03	Malfunction of tracheostomy stoma
J95.04	Tracheo-esophageal fistula following tracheostomy
J95.09	Other tracheostomy complication
Z43.0	Encounter for attention to tracheostomy
Z93.0	Tracheostomy status

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph

All codes that are not specified in the previous section.

Group 1 Codes

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
01/01/2020	R7	Revision Effective Date: 01/01/2020 REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217): Removed: “The link will be located here once it is available.” Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list 04/14/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.
01/01/2020	R6	Revision Effective Date: 01/01/2020 REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217): Added: Section and related information based on Final Rule 1713 ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY: Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity” ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY: Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity” 02/27/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.
01/01/2017	R5	02/21/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This is an article and not a local coverage determination.
01/01/2017	R4	Revision Effective Date: 01/01/2017 CODING GUIDELINES: Added: Clarification that tracheostomy tubes (A7520, A7521, 7522) are all-inclusive 04/12/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.
01/01/2017	R3	Revision Effective Date: 01/01/2017 POLICY SPECIFIC DOCUMENTATION REQUIREMENTS: Added: Diagnosis requirements RELATED LOCAL COVERAGE DOCUMENTS: Added: LCD-related Standard Documentation Requirements Language Article
07/01/2016	R2	Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.
10/01/2015	R1	Revision Effective Date: 08/01/2015 NON-MEDICAL NECESSITY AND PAYMENT RULES: Revised: Language for HCPCS codes A4450, A4452, A5120 when submitted without correct modifier

Associated Documents

Related Local Coverage Documents
Articles
A55426 - Standard Documentation Requirements for All Claims Submitted to DME MACs
LCDs
L33832 - Tracheostomy Care Supplies

Updated On	Effective Dates	Status
04/07/2022	01/01/2020 - N/A	Currently in Effect	You are here
02/21/2020	01/01/2020 - N/A	Superseded	View
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Tracheostomy Care Supplies - Policy Article

Contractor Information

Article Information

General Information

Article Guidance

Coding Information

CPT/HCPCS Codes

ICD-10-CM Codes that Support Medical Necessity

Group 1

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

ICD-10-PCS Codes

Additional ICD-10 Information

Bill Type Codes

Revenue Codes

Revision History Information

Associated Documents

Keywords

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