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LCD - Tracheostomy

Coverage Summary

  1. Written order prior to delivery
  2. 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.

Note: Tracheostomy supplies are non-covered for DME providers when the patient is receiving Home Health services. Home Health must provide tracheostomy supplies when receiving Home Health services.

Order Requirements

  1. Patient's Name
  2. Detailed description of specific supply being ordered
  3. Qty to be dispensed
  4. Length of Medical Need (ie, lifetime or other)
  5. Ordering Physician’s NPI
  6. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance.)
  7. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance.)
  8. Start date of the order – if different than signature date.

Coverage Detail

Tracheostomy supplies are non-covered for DME providers when the patient is receiving Home Health services. Home Health must provide tracheostomy supplies when receiving Home Health services.

Supplies for care of a tracheostomy site are covered for a patient 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. Additional quantities are non-covered.

Items included in a tracheostomy care or cleaning starter kit (first two weeks of a new trach) may include:

  • 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)

Items included in a tracheostomy care kit for an established tracheostomy (after two weeks of a new trach) may include:

  • Tube brush (1)
  • Pipe cleaners (2)
  • Cotton tip applicators (2)
  • Twill tape (30 inches)
  • 4x4 Sponges (2)