A4481 — Tracheostoma filter, any type, any size, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- A Standard Written Order (SWO) must be received by the supplier before a claim is submitted for items addressed in this policy.
- For DMEPOS items requiring WOPD, the supplier must have a signed SWO/WOPD before delivery; WOPD may list the base item and associated separately billed options/supplies.
- Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor upon request.
- For refills, suppliers must contact the beneficiary (no sooner than 30 days before expected end) and document an affirmative response prior to dispensing; delivery may occur no sooner than 10 days before expected end.
Key Coverage Criteria
- Tracheostomy care/cleaning starter kit (HCPCS A4625) is covered following an open surgical tracheostomy for the immediate post-operative period.
- Tracheostomy supplies are covered when they meet Medicare criteria of being in a defined Medicare benefit category and are reasonable and necessary for diagnosis, treatment, or to improve functioning per SSA §1862(a)(1)(A) and other applicable Medicare rules.
1 Active Policy
L33832 — Tracheostomy Care Supplies
J19
Related Codes
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