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 (Payment Methodology) 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.]

Source: Rule 410-122-0209 — Tracheostomy Care Supplies, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-122-0209.

410‑122‑0010
Definitions 410‑122‑0020
Orders 410‑122‑0040
Prior Authorization 410‑122‑0080
Conditions of Coverage, Limitations, and Restrictions 410‑122‑0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients) 410‑122‑0180
Healthcare Common Procedure Coding System Level II Coding 410‑122‑0182
Legend 410‑122‑0184
Repairs, Servicing, Replacement, Delivery, and Dispensing 410‑122‑0186
Payment Methodology 410‑122‑0188
DMEPOS Rebate Agreements 410‑122‑0200
Pulse Oximeter for Home Use 410‑122‑0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea 410‑122‑0203
Oxygen and Oxygen Equipment 410‑122‑0204
Nebulizer 410‑122‑0205
Respiratory Assist Devices 410‑122‑0206
Intermittent Positive Pressure Breathing 410‑122‑0207
Respiratory Supplies 410‑122‑0208
Suction Pumps 410‑122‑0209
Tracheostomy Care Supplies 410‑122‑0210
Ventilators 410‑122‑0211
Cough Stimulating Device 410‑122‑0220
Pacemaker Monitor 410‑122‑0240
Apnea Monitors for Infants 410‑122‑0250
Breast Pumps 410‑122‑0260
Home Uterine Monitoring 410‑122‑0280
Heating/Cooling Accessories 410‑122‑0300
Light Therapy 410‑122‑0320
Manual Wheelchair Base 410‑122‑0325
Power Wheelchair Base 410‑122‑0330
Power-Operated Vehicle 410‑122‑0340
Wheelchair Options/Accessories 410‑122‑0360
Canes and Crutches 410‑122‑0365
Standing and Positioning Aids 410‑122‑0375
Walkers 410‑122‑0380
Hospital Beds 410‑122‑0400
Pressure Reducing Support Surfaces 410‑122‑0420
Hospital Bed Accessories 410‑122‑0475
Therapeutic Shoes for Diabetics 410‑122‑0510
Osteogenesis Stimulator 410‑122‑0515
Neuromuscular Electrical Stimulator (NMES) 410‑122‑0520
Glucose Monitors and Diabetic Supplies 410‑122‑0525
External Insulin Infusion Pump 410‑122‑0540
Ostomy Supplies 410‑122‑0560
Urological Supplies 410‑122‑0580
Bath Supplies 410‑122‑0590
Patient Lifts 410‑122‑0600
Toilet Supplies 410‑122‑0620
Miscellaneous Supplies 410‑122‑0625
Surgical Dressing 410‑122‑0630
Incontinent Supplies 410‑122‑0640
Eye Prostheses 410‑122‑0655
External Breast Prostheses 410‑122‑0658
Gradient Compression Stockings/Sleeves 410‑122‑0660
Orthotics and Prosthetics 410‑122‑0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses 410‑122‑0678
Dynamic Adjustable Extension/Flexion Device 410‑122‑0680
Facial Prostheses 410‑122‑0700
Negative Pressure Wound Therapy Pumps 410‑122‑0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0209’s source at or​.us