All temporary Durable Medical Equipment (DME) policy flexibilities outlined in COVID-19 Special Bulletins remain in effect as of this publication date. See COVID-19 Special Bulletins for details.
An amended version of Clinical Coverage Policy 5A-2, Respiratory Equipment and Supplies with an effective date of April 1, 2021, was posted to the NC Medicaid Clinical Coverage Policy web page. Following is a summary of updates:
In the table Related Clinical Coverage Policies, added references to:
- 5A-3, Nursing Equipment and Supplies
- 5B, Orthotics and Prosthetics
In Subsection 5.3.4, the heading Cough-Stimulating Device, Alternating Positive and Negative Airway Pressure, was renamed Mechanical Insufflation - Exsufflation Devices. Other references to the term “cough-stimulating device” were also changed to “mechanical insufflation - exsufflation device”.
New Subsection 5.3.5, Tracheostomy Supplies, and the following medical necessity criteria, without PA, were added:
Medicaid and NCHC shall consider supplies for the care of a tracheostomy site medically necessary following an open surgical tracheostomy which has been opened or is expected to remain open for at least three months.
A tracheostomy care kit for a new tracheostomy is considered medically necessary during the first two (2) postoperative weeks. The following supplies should be included in the kit:
a. 1-plastic tray
b. 1-basin
c. 1-pair sterile gloves
d. 1-tube brush
e. 3-pipe cleaners
f. 1-pre-cut tracheostomy dressing
g. 1-roll gauze
h. 4-4x4 sponges
i. 2-cotton tip applicators
j. 30 inches-twill tape
A tracheostomy care kit for an established tracheostomy is considered medically necessary after the first two postoperative weeks. The following supplies should be included in the kit:
a. 1-tube brush
b. 2-pipe cleaners
c. 2-cotton tip applicators
d. 30 inches-twill tape
e. 2- 4x4 sponges
Quantities included in a tracheostomy care kit are to provide ALL necessary supplies for the care of the tracheostomy site. Additional supplies may be considered medically necessary ONLY for the care of another site, such as a speaking valve.
Note: A tracheostomy or laryngectomy tube plug or stop is used as an alternative to a tracheostomy laryngectomy tube.
Note: The HCPCS code for tracheostomy tube collar or holder should not be used for twill ties, twill tape or equivalent fabric or plastic supplies.
In Attachment A: Claims-Related Information, Section B, ICD-10-CM Diagnosis Code(s) were updated for mechanical insufflation - exsufflation devices.
In Attachment A: Claims-Related Information, Section C: Procedure Code(s), the following updates were made:
Coverage and quantity limits were added for HCPCS codes A4481 (tracheostomy filter, any type, any size, each), A7501 (tracheostoma valve, including diaphragm, each), A7502 (replacement diaphragm/faceplate for tracheostoma valve, each), A7503 (filter holder or filter cap, reusable, for use in a tracheostoma valve, each), A7504 (filter for use in tracheostoma heat and moisture exchange system, each), A7505 (housing reusable without adhesive, for use in heat and moisture exchange system and/or with a tracheostoma valve, each), A7506 (adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type), A7507 (filter holder integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each), A7508 (housing and integrated adhesive, for use in tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each), A7509 (filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each) and A7524 (tracheostomy stent/stud/button, each).
Quantity limits were updated for existing HCPCS codes A4623 (tracheostomy, inner cannula), A4626 (tracheostomy cleaning brush, each), A7520 (tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride (PVC), silicone or equal, each), A7521 (tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC) silicone or equal, each), A7522 (tracheostomy/laryngectomy tube, stainless steel or equal (serializable and reusable), each), A7525 (tracheostomy mask, each) and A7526 (Tracheostomy tube collar/holder, each).
Additional Resources
The DME fee schedule and full text of Clinical Coverage Policy 5A-2, Respiratory Equipment and Supplies is available at NC Medicaid’s Durable Medical Equipment (DME) web page. All COVID-19 Special Bulletins are available here.