Suction Pumps

Affected Providers

Treating practitioners and DME suppliers who bill for suction pumps.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Suction Pumps (L33612) and Article: Suction Pumps (A52519) have the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for suction pumps is 33.5%, with a projected improper payment amount of $4.7 million.

Denial Reasons

Insufficient documentation accounted for 67.2% of improper payments for suction pumps during the 2024 reporting period, while medical necessity (2.6%), no documentation (1.6%), and other errors (28.6%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

We cover suction equipment under the DME benefit. You must meet the provisions in LCD L33612 and Article A52519.

Gastric Suction

A gastric suction pump (HCPCS code E2000) removes gastrointestinal fluids under continuous or intermittent suction through a tube. We cover a gastric suction pump and related supplies for patients who can’t empty gastric secretions through normal gastrointestinal functions. We deny a gastric suction pump for other conditions as not reasonable and necessary.

We cover supplies (tubing, tape, dressings, etc.) separately when they’re medically necessary and used with a medically necessary E2000 pump. We deny supplies used with DME that aren’t reasonable and necessary.

Respiratory Suction

We cover a respiratory suction pump (HCPCS code E0600) only for patients who have difficulty raising and clearing secretions secondary to:

• Cancer or surgery of the throat or mouth
• Dysfunction of the swallowing muscles
• Unconsciousness or obtunded state
• Tracheostomy

We deny a respiratory suction pump for other conditions as not reasonable and necessary.

We cover suction catheters (HCPCS codes A4605, A4624, and A4628) and sterile water or saline (HCPCS codes A4216 and A4217) as separately payable when they’re medically necessary and used with a medically necessary E0600 pump. We deny supplies used with DME that aren’t reasonable and necessary.

We cover A4605 and A4624 only for patients with a tracheostomy (find the ICD-10-CM Codes that Support Medical Necessity section in Article A52519).

Tracheal suction catheters (A4624) are reasonable and necessary only when the patient meets these conditions:

• Has a tracheostomy
• Requires a covered respiratory suction pump (E0600), as described above, for tracheostomy suctioning

Closed system catheters (A4605) are reasonable and necessary only when the patient meets these conditions:

• Has a tracheostomy
• Requires a covered respiratory suction pump (E0600) for tracheostomy suctioning
• Requires a covered ventilator (see Medicare National Coverage Determinations Manual, Chapter 1, Part 4, section 280.1)

We deny more than 3 A4624 catheters per day as not reasonable and necessary for tracheostomy suctioning.

Non-tracheal suction catheters (HCPCS code A4628) are reasonable and necessary for suctioning in the oropharynx. The oropharynx isn’t sterile, so the catheter can be reused if properly cleansed or disinfected. We deny more than 3 A4628 catheters per week as not reasonable and necessary for suctioning.

The HCPCS code A7047 device isn’t used to remove secretions for the covered indications. We deny claims for A7047 as not reasonable and necessary.

We cover sterile water or saline solution (A4216 and A4217) when used to clear a suction catheter after tracheostomy suctioning. We deny sterile water or saline as not reasonable and necessary when used for oropharyngeal suctioning.

Wound Suction

Using suction on wounds (HCPCS codes A9272 and K0743) is appropriate only in clinical scenarios where the quantity of exudate exceeds the capacity of conservative measures like surgical dressings and wound fillers to contain it.

You can use wound suction to remove exudate using non-covered, disposable suction devices (A9272) or with covered DME devices (K0743). When a non-covered alternative exists (A9272), it isn’t reasonable or necessary to use a covered DME item (K0743); so, when you bill K0743, we deny it as not reasonable and necessary.

See the related Article A52519 for more information about the statutory requirements for disposable wound suction items (HCPCS codes A9270 and A9272).

We deny as not reasonable and necessary the wound suction pumps and their associated supplies that haven’t been specifically named as being qualified to use with K0743 through written instructions from the Pricing, Data Analysis, and Coding Contractor.

We cover supplies (dressings, tubing, etc.) as separately payable when they’re medically necessary and used with a medically necessary K0743 pump. We deny supplies used with DME that aren’t reasonable and necessary.

Refill Requirements

For DMEPOS items and supplies provided on a recurring basis, base your billing on prospective, not retrospective use.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.

Example of Improper Payments Due to Insufficient Documentation for Suction Pumps

A supplier bills the claim for HCPCS A4605 (Tracheal suction catheter, closed system, each) and submits the following documentation per the review contractor’s request:

• Standard written order with correct HCPCS coding
• Treating practitioner’s medical record that doesn’t meet the criteria for reasonable and necessary
• Proof of delivery

What Documentation Was Missing?

Although the patient’s medical record provided documentation that they meet the basic coverage criteria for a suction catheter, it didn’t have a complete description stating that the patient requires closed system catheters (like requiring the use of a covered ventilator).

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the Medicare Administrative Contractor recoups payment.

Recommendation

To prevent claim denials and improper payments, the certifying physician must document in the patient’s medical record that the patient meets coverage criteria for a respiratory suction pump (E0600) and that the patient requires closed system catheters because of having a tracheostomy, requiring both a covered respiratory suction pump (E0600) and a covered ventilator.