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33.2.10 Tracheostomy Tubes
Standard tracheostomy tubes do not require prior authorization. Tracheostomy tubes billed with modifiers TF or TG must be prior authorized. Documentation of medical necessity and the manufacturer's suggested retail price (MSRP) must accompany the prior authorization request form.
One standard tracheostomy tube and/or one inner cannula is a benefit per month. If a client has a custom tracheostomy tube, no inner cannulas will be authorized. Disposable tracheostomy inner cannulas are not a benefit.
Providers must use procedure code A7520, A7521, or A7522 when billing tracheostomy tubes. Providers must add modifier TF when billing a tracheostomy with specialized functions. Providers must add modifier TG when billing a custom-made tracheostomy.
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