Tracheostomy Supplies

Posted: August 13, 2026

· Overview

· Eligible Providers

· TPL and Medicare

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization

· Billing

Overview

Tracheostomy supplies are used to clear and maintain the airway. A tracheostomy is a surgical incision that opens the windpipe to aid breathing.

Eligible Providers

The following may provide tracheostomy supplies:

· Federal qualified health centers

· Indian Health Services

· Home health agencies

· Hospitals

· Medical suppliers

· Pharmacies

· Rural health clinics

TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third-party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested. Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Tracheostomy supplies are covered for eligible Medical Assistance and MinnesotaCare members to clear and maintain the airway for members with tracheostomies.

Covered Services

Codes: A4450, A4452, A4608, A4623-A4626, A4628, A4629, A7501-A7527, S8189
MHCP covers the following tracheostomy supplies:

· Tracheostomy and laryngectomy tubes (A7520 through A7522)

· Tracheostomy tube collars and holders (A7526) and plugs and stops (A7527)

· Tracheostomy care kits for new (A4625) and established (A4629) tracheostomies

· Transtracheal oxygen catheters (A4608)

· Tracheal suction catheters (A4624)

· Oral or oropharyngeal suction catheters (A4628)

· Cleaning brushes (A4626)

· Shower protectors (A7523)

· Inner cannulas (A4623)

· Tracheostomy masks (A7525)

· Tracheostoma stents, studs, and buttons (A7524)

· Tracheostoma valves (A7501) and replacement diaphragms or faceplates (A7502) for valves

· The following for use in tracheostoma heat and moisture exchange systems:

· Filters (A7504) and reusable filter holders or caps (A7503, A7507, A7509)

· Housing (A7508) and reusable housing (A7505)

· Adhesive discs (A7506)

A tracheostomy starter kit is covered for four weeks following the initial tracheostomy surgery. After the initial four weeks, established tracheostomy kits are covered.

A tracheostomy care or cleaning starter kit (A4625) includes:

· Plastic tray

· Basin

· Sterile gloves

· Tube brush

· Pipe cleaners

· Dressing

· Gauze

· Sponges

· Cotton tip applicators

· Twill tape

A tracheostomy care kit for an established tracheostomy (A4629) includes:

· Tube brush

· Pipe cleaners

· Sponges

· Cotton tip applicators

· Twill tape

A tracheostomy collar or holder is used to secure a tracheostomy tube, restrict tube movement, and reduce risk of cannula disruption.

Heat and moisture exchange systems help people who have had their voice box surgically removed to partially restore functions previously performed by the nose and upper airway.

Tracheostomy or laryngectomy tubes with plugs or stops are used as alternatives to tracheostomy or laryngectomy tubes. HCPCS code A7527 is not separately reimbursable from HCPCS codes A7520 through A7522.

Most tracheostomy supplies are included in the per diem for members living in a nursing facility. Tracheostomy supplies are not included in the per diem for members living in an intermediate care facility for people with developmental disabilities (ICF/DD).

Refer to the Medical Supply Coverage Guide (PDF) for quantity limits and information on which items are included in the long-term care per diem.

Noncovered Services

MHCP does not cover the following:

· Quantities that exceed medical necessity for the member

· Most tracheostomy supplies for members living in nursing facilities

Authorization

Authorization is required for the following:

· Quantities over MHCP quantity limits

· Miscellaneous supplies billed with HCPCS code S8189 if the submitted combined charges are over $400

Submit authorization to the Medical Review Agent.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of the MHCP Provider Manual for general billing information.

Bill tracheostomy supplies using MN–ITS 837P Professional. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics, Orthotics, and Augmentative Devices MN–ITS user manual for general billing requirements and guidance when submitting claims.

· Use modifier NU for purchases.

· Use modifier U3 for specialized or customized tracheostomy tubes and supplies. Documentation for specialized or customized tracheostomy supplies must justify medical necessity for the specialization or customization.

· Bill HCPCS codes A4450 and A4452 with modifier AU when issued with a tracheostomy supply.

· Do not bill HCPCS code A7527 with A7520 through A7522.

Documentation must include the following:

· Member’s diagnosis; and

· Order; and

· Item to be dispensed; and

· Quantity of item needed per change; and

· Anticipated frequency of change.

Medical necessity is established at the time of initial order. Document the medical necessity of the number of units of tracheostomy supplies being dispensed. The original documentation must be less than 30 days old. A new order or ongoing supporting documentation explaining a change in required number of units is required only if there is a major change in the member’s condition.

Tracheostomy supplies are purchase items only. No more than one month’s supply of tracheostomy supplies may be provided at one time, unless the medical necessity of greater quantities is documented.