Local Coverage Article

Tracheostomy Care Supplies - Policy Article

A52492

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Contractor Information

Article Information

General Information

Article ID
A52492
Original ICD-9 Article ID
A33680
A27722
A47100
A33771
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
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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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 link will be located here once it is available.

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

Group 1

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
CodeDescription
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

Group 1

Group 1 Paragraph

All codes that are not specified in the previous section.

Group 1 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 DateRevision History NumberRevision History Explanation
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 National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
02/21/2020 01/01/2020 - N/A Currently in Effect You are here
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Keywords

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