Currentpriority healthPolicy BILLING POLICY No. 035

Tracheostomy supplies

Defines Priority Health's payment, coding, documentation, and quantity limits for tracheostomy supplies and which items will be denied; applies to providers submitting claims for Priority Health members.

Policy Summary

Payerpriority health

PolicyTracheostomy supplies

Policy CodePolicy BILLING POLICY No. 035

Change TypeMaterial additions and clarifications

Effective DateAug. 1, 2024

Next Review Date

Key ActionObtain and document a written order and proof of delivery before supplying tracheostomy items and limit dispensing to a maximum 3‑month quantity unless supported by documentation.

SourceLink

POLICY UPDATE CHANGES

Addition of diagnosis criteria (Z99.11 noted as usable when supported by documentation).

A7523 - Tracheostomy shower protector will be considered a convenience item and denied.

Added 'Place of service' section.

Added 'Disclaimer' section.

3 monthsmax dispensing period

150A5120 monthly max

62common HCPCS monthly max

initial kitA4625 timing

established kitA4629 timing

Coverage criteria for tracheostomy supplies

Covered when ALL of the following conditions are met:

ALL of the following

ALL of the following
- A written order for supplies must be on file and dated prior to receipt of supplies by the member.
- Proof of delivery must be documented in the medical record; failure to detail date of delivery may result in denial or recovery of overpayment.
ALL of the following
- Supplies should not be dispensed for more than a 3-month quantity.

Policy Summary

Payerpriority health

PolicyTracheostomy supplies

Policy CodePolicy BILLING POLICY No. 035

Change TypeMaterial additions and clarifications

Effective DateAug. 1, 2024

Next Review Date

Key ActionObtain and document a written order and proof of delivery before supplying tracheostomy items and limit dispensing to a maximum 3‑month quantity unless supported by documentation.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Specific monthly quantity limits are defined per HCPCS code (see policy list). Units exceeding these maximums require medical documentation review and will remain denied without supporting detail.
Examples of per‑month limits
- A4625 (starter kit) = 31 per month; A4629 (established kit) = 31 per month; A4626 (cleaning brush) = 2 per month (inclusive to kits and not reimbursed separately).
- A5120 = 150 per month; A4481, A4623, A7504, A7506, A7507, A7508, A7509 = 62 per month (common limits).
- Other examples: A4364 = 4; A4450 = 40; A4452 = 40; A4456 = 50; A7501/A7502 = 1 per month; A7503 = 1 per 6 months; A7505 = 2 per 3 months; A7520/A7521/A7524 = 1 per 3 months; A7522 = 1 per 12 months; A7526 = 31; A7527 = 2 per 3 months.

ALL of the following

Heat/moisture exchangers may be coded when supplied; HMEs are placed over the tracheostoma via a housing/cassette held by adhesive and may be used with a tracheostoma valve.
HME component coding
- A7503 = filter holder or filter cap (reusable with HME) — 1 per 6 months.
- A7504 = filter for tracheostoma with HME — 62 per month.
- A7506–A7509 = adhesive discs, holders, housings, and integrated filter/adhesive components — commonly 62 per month as specified.
Items not part of the HME system (e.g., A4481 tracheostoma filter with adhesive edge) are billed and limited separately.

HCPCS coding and quantity limits

Tracheostomy HCPCS coding guidanceHCPCS

A4625	Tracheostomy care/cleaning starter kit (provided within first two postoperative weeks)
A4629	Established tracheostomy care kit (after second postoperative weeks)
A4626	Tracheostomy cleaning brush (inclusive to A4625 and A4629; not reimbursed separately)
A7523	Tracheostomy shower protector (considered convenience item; denied)
A7520	Tracheostomy tube
A7501	Tracheostoma valve with diaphragm
A7503	Filter holder or filter cap (reusable with HME)
A7504	Filter for tracheostoma with HME
A4481	Tracheostoma filter with adhesive edge (not part of HME system list)
E1399/A9999	Unlisted codes for tracheostomy supplies require detailed description and justification; will be denied if unsupported

Per-month quantity limits — selected HCPCS

A43644 per month

A445040 per month

A462531 per month

A5120150 per month

A75031 per 6 months

A462931 per month

A4481/A4623/A7504/A7506-A750962 per month (common limit)

Documentation, authorization, and provider billing actions

Documentation Required

Documentation and authorization requirements — written orders, proof of delivery, 3‑month limit

Documentation must meet CMS standard requirements (see article A55426). Maintain a written order dated prior to the member receiving supplies and document all supporting clinical information in the medical record. The NTE segment of the electronic claim must include a narrative that states the number of months being billed in addition to the description of supplies. Proof of delivery, including the date of delivery, must be documented in the medical record; failure to document proof of delivery as required may result in claim denial or recovery of overpayment. Supplies should not be dispensed in quantities greater than a 3-month supply without medical justification; quantities exceeding published maximums require medical documentation review and may be denied if unsupported.

Written order dated prior to member receipt of supplies must be on file
NTE segment must state number of months being billed in addition to supply description
Proof of delivery (including delivery date) required in medical record
Supplies should not be dispensed for more than a 3-month quantity without documentation to support excess units
Units exceeding maximums will be subject to medical documentation review and may be denied

Documentation Required

Refill verification — member affirmation and documentation required

Automated refill deliveries are discouraged. Suppliers must obtain and document explicit member affirmation before dispensing refills. Member-initiated refill requests must be recorded in the medical record. Validate and document any atypical utilization quantities with the treating/ordering clinician prior to dispensing.

Obtain member affirmation before automated refills are dispensed
Document member refill requests in the medical record
Validate atypical utilization with treating/ordering physician and document rationale

Denial Risk

Place of service and denial rules — inpatient discharge and excluded convenience items

Supplies with a date of service on or before the inpatient facility discharge date will be denied. Convenience items (e.g., A7523 Tracheostomy shower protector) are not covered and will be denied. Diagnosis coding must follow CMS, LCDs, and local articles; Z99.11 may be used when clinically supported.

Supplies with a date of service during or before an inpatient facility discharge will be denied
A7523 — Tracheostomy shower protector considered a convenience item and will be denied
Diagnosis coding must be supported by clinical documentation; follow CMS and local coverage guidance (Z99.11 where appropriate)

Key definitions

Z99.11 — Diagnosis note

CodeZ99.11 — Dependence on respirator [ventilator] status

Usage noteMay be assigned when medically appropriate and fully supported by clinical documentation to support medical necessity

Policy alignmentPriority Health adheres to CMS and local coverage determinations regarding diagnosis coding to support medical necessity

Heat/moisture exchanger (HME)

DefinitionHeat/moisture exchanger (HME) — device that supplies warmth and humidity during inhalation and exhalation, replacing nasal/upper airway function

ComponentsTypically includes a plastic housing cassette/holder and is held in place by an adhesive

Optional interfacesCan be used alone or in conjunction with a tracheostoma valve

Context of usePlaced over the tracheostoma to supply humidity and warmth for tracheostomy patients; may be coded when supplied