tubing, a manual resuscitation bag, or a speaking valve may be connected to the connector A portable home model suction pump is a lightweight compact electric aspirator designed for upper respiratory oropharyngeal and tracheal suction. Use of the device does not require technical or professional supervision.
Suction and Tracheal Supplies Policy Number: PG0277 Last Review: 08/14/2018 ADVANTAGE | ELITE | HMO INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement. SCOPE X Professional _ Facility DESCRIPTION A tracheostomy is an artificial opening in the neck into the trachea. In the hospital, tracheostomy care is performed under sterile technique, while in the home a clean technique is used. Tracheostomy care includes internal and external component cleaning and replacement, suctioning with airway maintenance, humidification, and skin care. The basic components of a tracheostomy that has been placed can include; Outer cannula - tube that is inserted into the trachea. It is intended to be permanent and may have an inner cannula within it Inner cannula - tube that fits inside outer tracheostomy tube. It is removed for cleaning or replacement Neck flange - component which has holes on either side for securing neck ties to hold cannula in place Connector - part of the tracheostomy tube or inner cannula which extends beyond the flange. Ventilator tubing, a manual resuscitation bag, or a speaking valve may be connected to the connector A portable home model suction pump is a lightweight compact electric aspirator designed for upper respiratory oropharyngeal and tracheal suction. Use of the device does not require technical or professional supervision. Home model suction machines are medically necessary durable medical equipment for members who have difficulty raising and clearing secretions secondary to any of the following conditions; 1. Cancer or surgery of the throat or mouth 2. Dysfunction of the swallowing muscles 3. Unconsciousness or obtunded state 4. Tracheostomy POLICY Standard tracheostomy tubes (A7520, A7521, A7522) do not require prior authorization. Custom-made or modified tracheostomy/laryngectomy tubes (A7520-U1, A7520-U2, A7520-U3, A7521-U1, A7521-U2, A7521-U3) do not require prior authorization for Advantage. Modifiers U1, U2, U3 are not applicable for HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan. Suction and Tracheal Supplies (A4216, A4481, A4605, A4623, A4624, A4625, A4626, A4628, A4629, A7000, A7001, A7002, A7501, A7502, A7503, A7504, A7505, A7506, A7507, A7508, A7509, A7523, A7524, A7525, A7526, A7527, E0600) do not require prior authorization. PG0277 12/18/2020 Limits may apply as listed below in CODING/BILLING INFORMATION. COVERAGE CRITERIA HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage Supplies for care of a tracheostomy site are considered medically necessary for a member following an open surgical tracheostomy which has been open or is expected to remain open for at least three months. A tracheostomy care or cleaning starter kit considered medically necessary following an open surgical tracheostomy. Beginning two weeks post-operatively, a tracheostomy care or cleaning starter kit is no longer considered medically necessary. 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. One tracheostomy care kit (A4625 or A4629) per day is considered necessary for routine care of a tracheostomy. Claims for additional kits for non-routine tracheostomy care must be accompanied by substantiating documentation within a member appeal. A4626 is included in the allowance for A4625 and A2629 when provided at the same time. When billed together, the A4626 will deny. 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. 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. A tracheostomy/laryngectomy tube plug/stop is used as an alternative to a tracheostomy/laryngectomy tube and therefore for a member receiving a tracheostomy/laryngectomy tube plug/stop (A7527), a tracheostomy/laryngectomy tube (A7520, A7521, A7522) is considered not medically necessary. When a suction pump is used for tracheal suctioning, other supplies (e.g., cups, basins, gloves, solutions, etc.) included within the tracheal care kit are considered medically necessary. There is no need to purchase additional supplies when the kits contain all the required supplies. When a suction pump is used for oropharyngeal suctioning, the other supplies are not considered medically necessary. These kits reflect the necessary supplies utilized in this type of suctioning. The table below lists the maximum number of items/units of service that are usually medically necessary. The actual quantity needed for a particular member may be more or less than the amount listed depending on clinical factors that affect the frequency of supply changes. The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the member's medical record. Advantage Providers must use procedure code A7520 or A7521 with modifiers U1, U2, and U3 when billing a custom-made or modified tracheostomy/laryngectomy. Documentation of medical necessity and the manufacturer's suggested retail price (MSRP) must be provided upon request when tracheostomy tubes are billed with these modifiers. HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan Modifiers U1, U2, U3 are not applicable. PG0277 12/18/2020 CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered. HMO, PPO, Individual HCPCS CODES Marketplace, Advantage Elite/ProMedica Medicare Plan Tracheostomy supplies Usual Medically Necessary Quantity: A4481 Tracheostoma filter, any type, any size, each 62 PER MO 62 PER MO A4623 Tracheostomy, inner cannula 62 PER MO 31 PER MO A7501 Tracheostoma valve, including diaphragm, each 1 PER MO 1 PER MO A7502 Replacement diaphragm/faceplate for tracheostoma valve, each 1 PER MO 1 PER MO Filter holder or filter cap, reusable, for use in a A7503 tracheostoma heat and moisture exchange system, 1 PER MO 1 PER MO each A7504 Filter for use in a tracheostoma heat and moisture exchange system, each 100 PER MO 100 PER MO Housing, reusable without adhesive, for use in a heat A7505 and moisture exchange system and/or with a 4 PER MO 4 PER MO tracheostoma valve, each A7506 Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each 100 PER MO 100 PER MO A7507 Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each 100 PER MO 100 PER MO A7508 Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each 100 PER MO 100 PER MO A7509 Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each 100 PER MO 100 PER MO A7520 Tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride(PVC), silicone or equal, each 2 PER MO 2 PER MO A7520- Custom-made U1 N/A 2 PER MO A7520- Stock with modifications--pediatric U2 N/A 2 PER MO A7520- Standard or stock with modifications U3 N/A 2 PER MO A7521 Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each 2 PER MO 2 PER MO A7521- Custom-made U1 N/A 2 PER MO A7521- Standard or stock, with modifications--pediatric U2 N/A 2 PER MO A7521- Cuffed, standard or stock with modifications--pediatric U3 or adult N/A 2 PER MO PG0277 12/18/2020 A7522 A7523 A7524 A7525 A7526 Tracheostomy/laryngectomy tube, stainless steel/equal (sterilizable and reusable), each Tracheostomy shower protector, each Tracheostoma stent/stud/button, each Tracheostomy mask, each Tracheostomy tube collar/holder, each A7527 Tracheostomy/laryngectomy tube plug/stop, each Oral and tracheal suction supplies A4216 Sterile water, saline and/or dextrose (diluent), 10ml A4605 Tracheal suction catheter, closed system, each A4624 A4628 A7000 A7001 A7002 E0600 Tracheal suction catheter, any type other than closed system, each Oropharyngeal suction catheter, each Canister, disposable, used with suction pump, each Canister, non-disposable, used with suction pump, each Tubing, used with suction pump, each Respiratory suction pump, home model, portable or stationary, electric Tracheostomy cleaning supplies A4625 Tracheostomy care kit for new tracheostomy A4626 Tracheostomy cleaning brush, each A4629 Tracheostomy care kit for established tracheostomy 2 PER MO 2 PER MO 1 PER MO 1 PER MO 1 PER MO 1 PER MO 4 PER MO 4 PER MO 31 PER MO 15 PER MO 1 PER MO 1 PER MO Usual Medically Necessary Quantity: 100 PER MO 100 PER MO 15 PER MO 15 PER MO 150 PER MO 150 PER MO 12 PER MO 4 PER MO 3 PER MO 3 PER MO 2 PER YR 2 PER YR 4 PER MO 4 PER MO ALLOW 1 PER 4 YRS Usual Medically Necessary Quantity: 31 PER MO 31 PER MO 15 PER MO 15 PER MO 31 PER MO 31 PER MO REVISION HISTORY EXPLANATION ORIGINAL EFFECTIVE DATE: 08/01/2009 07/12/16: Providers must use procedure code A7520 or A7521 with modifier U1 when billing a custom-made tracheostomy/laryngectomy. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 08/14/18: Effective 7/16/18 added modifiers U2 & U3 for codes A7520 & A7521 as covered with limit of 2 per month for Advantage per ODM guidelines. Modifiers U1-U3 are N/A for HMO, PPO, Individual Marketplace, Elite. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 12/18/2020: Medical policy placed on the new Paramount Medical Policy Format REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review Hayes, Inc. PG0277 12/18/2020Microsoft Word 2016 Microsoft Word 2016