J95.04 — Tracheo-esophageal fistula following tracheostomy
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for specified HCPCS codes per Final Rule 1713; WOPD must be obtained prior to delivery or the claim is deniable.
- The diagnosis code that justifies the need for tracheostomy supplies must be included on each claim.
- When codes A4450, A4452, and A5120 are used with tracheostomy care supplies they must be billed with the AU modifier; these are the only codes eligible for AU modifier under this policy.
- Suppliers must follow the LCD-related Standard Documentation Requirements article (A55426) for general documentation; failure to meet those standard documentation requirements may result in denial.
Key Coverage Criteria
- Tracheostomy care supplies are covered for beneficiaries following an open surgical tracheostomy that has been open or is expected to remain open for at least 3 months.
- Tracheostomy care starter kit (A4625) is used for tracheostomy care provided in the first two postoperative weeks.
- Tracheostomy care kit for an established tracheostomy (A4629) is used for tracheostomy care provided after the first two postoperative weeks.
- Heat/Moisture Exchangers (HME) components (A7503, A7504, A7506, A7507, A7508, A7509) are appropriate for laryngectomees or other beneficiaries when clinically indicated and may be used with or without a tracheostoma valve (A7501).
- Portable or stationary home model respiratory suction pumps (HCPCS E0600) are covered under DME when reasonable and necessary per the related LCD and statutory payment requirements for oropharyngeal and tracheal secretion removal or similar indicated uses (e.g., some airway-enlarging OSA devices).
- Portable or stationary gastric suction pumps (HCPCS E2000) are covered when reasonable and necessary per the related LCD for removal of gastrointestinal secretions.
10 Active Policies
A52519 — Suction Pumps - Policy Article
J19
A52492 — Tracheostomy Care Supplies - Policy Article
J19
A56717 — Billing and Coding: Respiratory Therapy (Respiratory Care)
A57224 — Billing and Coding: Respiratory Care
L34430 — Respiratory Therapy (Respiratory Care)
Related Codes
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