Tracheostomy Supplies

Affected Providers

Treating practitioners and DME suppliers who bill for tracheostomy supplies.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Tracheostomy Care Supplies (L33832) has the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for tracheostomy supplies is 25.6%, with a projected improper payment amount of $6.5 million.

We cover tracheostomy supplies under the prosthetic benefit. We outline other policy requirements in LCD L33832 and Article: Tracheostomy Care Supplies (A52492).

Denial Reasons

Insufficient documentation accounted for 55.9% of improper payments for tracheostomy supplies during the 2024 reporting period, while medical necessity (2.8%) and other errors (41.2%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

We cover tracheostomy care or a cleaning starter kit (HCPCS code A4625) after an open surgical tracheostomy. Starting 2 weeks after the operation, we consider code A4625 no longer medically necessary, and if you bill that code, we deny it as not reasonable and necessary.

The Usual Maximum Quantity of Supplies table in LCD L33832 lists the greatest number of items or units of service usually reasonable and necessary.

The actual quantity needed for a particular patient may be more or less than the amount listed, depending on clinical factors that affect the frequency of supply changes.

Clearly document in the patient’s medical record the explanation for using more supplies than the amounts listed. If you don’t provide documentation when requested, we deny the excess quantities as not reasonable and necessary.

Regardless of use, a supplier must not dispense more than a 1-month supply at a time for a patient in a nursing facility and more than a 3-month supply at a time for a patient at home.

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 DMEPOS Refill Record

A supplier bills for a refill of HCPCS code A4623 (Tracheostomy, inner cannula) and submits this documentation per the review contractor’s request:

• A record that’s missing documentation that the patient requested or confirmed their need for the refill
• A refill order
• The treating practitioner’s clinical record
• Proof of delivery

What Documentation Was Missing?

There wasn’t documentation in the refill indicating the patient communicated their need for more supplies.

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 collect and submit proper documentation for DMEPOS refills.