Medicare covers medically necessary tracheostomy supplies under the prosthetic benefit. For any item to be covered under Medicare it must be “1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).” Many tracheostomy supplies were improperly billed due to insufficient documentation.
It is important to understand how to document appropriately in order to get reimbursed appropriately. Here is the CMS information for tips in order to document sufficient information.
Standard Documentation Requirements for All Claims Submitted to DME– provides guidance to assist Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers in understanding the information necessary to justify payment and reduce denials.
Medicare Documentation Checklist for Tracheostomy Supplies– a checklist to ensure suppliers gather all the appropriate documentation for tracheostomy supplies
Medicare Documentation Checklist for Suction Pumps– a checklist to ensure suppliers gather all the appropriate documentation for suction pumps.
Medicare Documentation Checklist for Nebulizers– a checklist to ensure suppliers gather all the appropriate documentation for nebulizers.
Clinician Checklist for Tracheostomy Care Supplies– a checklist to assist clinicians in determining what documentation they need to have available for suppliers.
Local Coverage Determination– Provides information on indications, limitations and medical necessity of tracheostomy supplies. The usual number of each type of supply for patients with tracheostomy is listed. The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiary’s medical record. If adequate documentation is not provided when requested, the excess quantities will be denied as not reasonable and necessary.
