OAR 410-122-0209: Tracheostomy Care Supplies

(1) Indications and Coverage: For a client following an open surgical tracheostomy that has been open or is expected to remain open for at least three months: (a) Standard tracheostomy supplies, including tracheostomy tubes (A7520, A7521), do not require prior authorization; (b) Custom/Specialized tracheostomy tubes must be a device that requires the manufacturer to complete substantive customization or modification for a specific individual’s medical need; (c) Custom/Specialized tracheostomy tubes require prior authorization and shall be approved with clinical documentation supporting the medical appropriateness and a statement from the prescribing practitioner explaining why a standard or off-the-shelf tracheostomy tube will not meet the client’s medical needs. (2) Documentation: (a) A prescription for tracheal equipment that is signed by the prescribing practitioner shall be kept on file by the DMEPOS provider. The prescribing practitioner’s records shall contain information that supports the medical appropriateness of the item ordered; (b) Custom/Specialized tracheostomy tubes require an assessment every six months indicating a standard tracheostomy tube does not currently meet the medical needs of the client. Documentation shall be submitted to the Division at the time of request. (3) Billing: (a) Custom/Specialized tracheostomy tubes shall be billed using the correct HCPCS code and modifier 22; (b) Custom/Specialized tracheostomy tubes shall be reimbursed following the payment methodology outlined in OAR 410-122-0186 for manually priced items. (4) Procedure Codes – Table 122-0209. [ED. NOTE: Tables referenced are available from the agency.] [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]