c sup prod trach t

Medical Supply Products: Tracheostomy – T thru Z Manufacturers 1

This section lists the billing codes, manufacturer codes and units for tracheostomy supplies manufactured by companies with names that begin with the letters T-Z. In this section “MAC” refers to maximum acquisition cost and “UPN” refers to the Universal Product Number. For additional help, refer to the Medical Supplies section in this manual. HCPCS codes are for reference only.

Treatment Authorization Requests (TARs) are issued only for products that exceed billing limitations, or where otherwise indicated. Miscellaneous procedure codes, such as 9999A or 9999C, may not be substituted.

MAC Guarantee Through The Department of Health Care Services (DHCS) negotiated a contract with a distributor, Independence Medical, to

Independence Medical Only establish maximum acquisition cost (MAC) agreements for tracheostomy products. The maximum acquisition cost listed in the “MAC” column in this section reflects the guaranteed MAC only when providers buy tracheostomy products through Independence Medical. This price is not guaranteed if providers purchase directly from the manufacturer or another source. “Item” numbers listed in this section are Independence Medical item numbers.

Billing Instructions Claims submitted for contracted tracheostomy products must include both the billing code and either the UPN or item number. All attachments submitted with paper claims (invoice, catalog page or price list) must include the UPN or item number for the product being billed. If the UPN or item number is not pre-printed on the attachment, it should be handwritten on the attachment next to the supply for which it is required. If the UPN or item number is not included or is illegible the claim will be denied.

Computer Media Claims require the UPN or item number to be included in the Remarks field. All tracheostomy products must be billed to Medicare before being billing to Medi-Cal.

Effective Dates Tracheostomy products in this section are effective for dates of service on or after November 1, 2008, unless
otherwise noted.

2 – Medical Supply Products: Tracheostomy – T thru Z Manufacturers October 2008

mc sup prod trach t

Medical Supply Products: Tracheostomy – T thru Z Manufacturers 3

Billing Limitations Tracheostomy supplies are limited to the following quantities without authorization.

Billing Code / Limitation
9916L, 9916M, 9916S, 9916U, 9916W / No more than 90 in an 81-day period
9916N, 9916Y, 9916Z / No more than 6 in an 81-day period
9916P, 9916Q, 9917P, 9917Q, 9917V / No more than 3 in an 81-day period
9916R, 9916V, 9916X / No more than 1 unit per dispensing and 4 dispensings in a year
9916T / No more than 12 in a 365-day period
9917S / No more than 15 in an 81-day period
9917T / No more than 12 in an 81-day period
9917U / No more than 18 in an 81-day period

9981E, 9981F, 9981J

/

No more than 90 in an 81-day period

9981F / No more than 360 in an 81-day period

Medical Supply Code 9916X: For instructions to bill medical supply codes 9916X (filter holder and integrated filter housing, and adhesive, for use as a

Billing Instructions heat and moisture exchange system), see “Filter Holder and Integrated Filter Housing: Medical Supply Code 9916X” section of this manual.

2 – Medical Supply Products: Tracheostomy – A thru F Manufacturers ___ 2008

mc sup prod trach t

3

TRACHEOSTOMY
Description /
Item
Number /
UPN / HCPCS (reference only) /
Billing
Code /
MAC /
Unit of
Measure
Torbot Company – TT
United contour trach tube brush, small / TRSN604300 / 00806278001110 / A4626 / 9916N / $7.33 / each
United contour trach tube brush, medium / TRSN604200 / 00806278001103 / A4626 / 9916N / $7.33 / each
United contour trach tube brush, large, straight, 8" long / TRSN604100 / 00806278001097 / A4626 / 9916N / $7.33 / each
United contour brush, 5/16" x 20" / TRSN601100 / 00806278000984 / A4626 / 9916N / $9.16 / each
Welcon – 3W
Tracheostomy neckband / WE2740 / H66027401 / A7526 / 9917U / $1.45 / each
Tracheostomy tube holder non-sterile tie / WE2710 / H66027101 / A7526 / 9917U / $0.76 / each
Tracheostomy Care Kit w/peel back lid, removable basin / WE2760 / H660276021 / A4629 / 9981E / $1.10 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – T thru Z Manufacturers October 2008