Suction Pumps

Number: 0503

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

Policy

Scope of Policy

This Clinical Policy Bulletin addresses suction pumps.

  1. Medical Necessity

    Aetna considers the following suction pumps and associated supplies medically necessary:

    1. Respiratory Suction Pump

      1. Home model respiratory suction machines as durable medical equipment for members who have difficulty raising and clearing secretions secondary to any of the following conditions:

        1. Cancer or surgery of the throat or mouth; or
        2. Dysfunction of the swallowing muscles; or
        3. Tracheostomy; or
        4. Unconsciousness or obtunded state.

        Aetna considers respiratory suction pumps experimental and investigational for all other indications because of insufficient evidence of effectiveness for other indications.

      2. Tracheal suction catheters and sterile water/saline as supplies for suction pumps.

        1. Closed system catheters when all of the following are met:

          1. The member has a tracheostomy; and
          2. The member requires the use of a medically necessary respiratory suction pump, as described above, for tracheostomy suctioning; and
          3. The member requires the use of a medically necessary ventilator.
        2. Tracheal suction catheters other than closed system catheters when all of the following are met:

          1. The member has a tracheostomy; and
          2. The member requires the use of a medically necessary respiratory suction pump, as described above, for tracheostomy suctioning.
        3. More than three tracheal suction catheters other than closed system per day are considered not medically necessary for tracheostomy suctioning.

          1. In most cases, in the home setting, sterile catheters are considered medically necessary only for tracheostomy suctioning.
          2. Three suction catheters per day are considered medically necessary for tracheostomy suctioning, unless additional documentation is provided. When a tracheal suction catheter is used in the oropharynx, which is not sterile, the catheter can be re-used if properly cleansed and/or disinfected. In this situation the medical necessity for more than 3 catheters per week would require additional documentation.
        4. An oral interface used with a respiratory suction pump is considered not medically necessary because it is not used to remove secretions for the indications described above.

        5. Sterile saline solution when used to clear a suction catheter after tracheostomy suctioning. It is not usually considered medically necessary for oropharyngeal suctioning.
    2. The following supplies for use with a suction pump:

      1. Disposable or non-disposable canister used with suction pump;
      2. Oropharyngeal suction catheters;
      3. Tubing used with suction pump.

      When a suction pump is used for tracheal suctioning, other supplies (e.g., basins, cups, gloves, solutions, etc.) included with the tracheal care kit are considered medically necessary. When a suction pump is used for oropharyngeal suctioning, these other supplies are not considered medically necessary.

    3. Gastric Suction Pump

      1. Use of a gastric suction pump and related supplies for members who are unable to empty gastric secretions through normal gastrointestinal functions. A gastric suction pump is used to remove gastrointestinal fluids under continuous or intermittent suction via a tube. Gastric suction pumps are considered experimental and investigational for all other indications.
      2. Supplies (tubing, tape, dressings, etc.) for use with a medically necessary gastric suction pump.

    4. Wound Suction Pumps

      1. Use of suction on wounds only in those clinical scenarios where the quantity of exudate exceeds the capacity of conservative measures such as surgical dressings and wound fillers to contain it. However, wound suction to remove exudate can be accomplished with the use of disposable, suction devices, which are considered supplies, or with portable home model suction pumps, which are considered DME.
      2. Supplies (dressings, tubing, etc.) when they are used with a medically necessary portable home model suction pump for use on wounds.

      Note: When a disposable suction device alternative exists, it is not considered medically necessary to use a portable home model suction pump for use on wounds. Note: Disposable suction devices are not covered under plans that exclude supplies.

  2. Policy Limitations and Exclusions 

    Saline used for tracheal lavage is considered a supply, and is not covered under plans that exclude supplies.

    All items used with any suction pump, such as tracheal suction catheters, sterile water, saline used for suctioning, dressings, gastric tubes, etc. (not all-inclusive) are considered to be supplies for durable medical equipment.

    Disposable wound suction devices and related supplies are considered supplies and are not considered DME; they are not covered under plans that exclude supplies.

  3. Related Policies

Table:

CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

HCPCS codes covered if selection criteria are met:
A4216 Sterile water, saline and/or dextrose, diluent/flush, 10 ml
A4217 Sterile water/saline, 500 ml
A4605 Tracheal suction catheter, closed system, each
A4624 Tracheal suction catheter, any type other than closed system, each
A4628 Oropharyngeal suction catheter, each
A4927 Gloves, non-sterile, per 100
A7000 Canister, disposable, used with suction pump, each
A7001 Canister, non-disposable, used with suction pump, each
A7002 Tubing, used with suction pump, each
A9272 Wound suction, disposable, including dressing, all accessories and components, any type, each
E0600 Respiratory suction pump, home model, portable or stationary, electric
E2000 Gastric suction pump, home model, portable or stationary, electric
K0743 Suction pump, home model, portable, for use on wounds
K0744 Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 square inches or less
K0745 Absorptive wound dressing for use with suction pump, home model, portable, pad size more than 16 square inches but less than or equal to 48 square inches
K0746 Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 square inches

Other HCPCS codes related to the CPB:
A4481 Tracheostoma filter, any type, any size, each
A4623 Tracheostomy, inner cannula
A4629 Tracheostomy care kit for established tracheostomy
A7047 Oral interface used with respiratory suction pump, each
A7501 - A7527 Tracheostomy supplies

ICD-10 codes covered if selection criteria are met:
C03.0 - C06.9
C09.0 - C14.8		 Malignant neoplasm of gum, oral cavity and pharynx
D00.00 - D00.08 Carcinoma in situ of lip, oral cavity, and pharynx
D00.1 Carcinoma in situ of esophagus
D10.0 - D11.9
D13.0		 Benign neoplasm of mouth, pharynx, oral cavity, major salivary glands and esophagus
J39.0 - J39.2 Other diseases of pharynx
K31.84 Gastroparesis
R13.0 - R13.19 Aphagia and dysphagia
R40.0 - R40.4 Somnolence, stupor and coma
Z93.0 Tracheostomy status

Background

A portable home model suction pump is a light-weight, compact, electric aspirator designed for upper respiratory, oral pharyngeal and tracheal suction for use in the home.  Use of the device does not require technical or professional supervision. A stationary home model respiratory suction pump is an electric aspirator designed for oropharyngeal and tracheal suction.

A portable or stationary home model gastric suction pump is an electric aspirator designed to remove gastrointestinal secretions. 

A closed system tracheal suction catheter is a type of suction catheter that is protected by an outer sheath. It is connected to the ventilator circuit of a person on mechanical ventilation and left in place. Suctioning is accomplished without disconnection from ventilation. 

A tracheal suction catheter is a long, flexible catheter. 

An oropharyngeal catheter is a short, rigid (usually) plastic catheter of durable construction. 

Wound suction is provided with an integrated system of components. This system contains a pump and dressing sets. It does not include a separate collection canister, a defining component of Negative Pressure Wound Therapy (NPWT). Instead, exudate is retained in the dressing materials. Wound suction systems that do not contain all of the required components are not classified as wound suction systems.

A portable home model suction pump for use on wounds describes a suction pump for wounds which provides controlled subatmospheric pressure that is designed for use with dressings, without a canister. 

An absorptive wound dressing for use with a portable home model suction pump describes an allowance for dressing sets which are used in conjunction with a stationary or portable suction pump but not used with a canister. Each of these absorptive wound dressings is used for a single, complete dressing change, and contains all necessary components, including but not limited to non-adherent porous dressing, drainage tubing, and an occlusive dressing which creates a seal around the wound site for maintaining subatmospheric pressure at the wound. These dressing sets are selected based upon wound size using the smallest size necessary to cover the wound. For multiple wounds located close together, a single large dressing must be used rather than multiple smaller dressing sets if it is possible to fit the wounds under a single larger dressing set. 

A disposable wound suction including dressing and accessories describes a disposable wound suction device. Suction is developed through the use of any type of mechanism. This device includes all components, accessories and dressings.

References

The above policy is based on the following references:

  1. American Association for Respiratory Care (AARC). Suctioning of the patient in the home. AARC Clinical Practice Guidelines. Respir Care. 1999;44(1):91-98.
  2. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1). Baltimore, MD: CMS; effective July 5, 2005.
  3. NHIC, Corp. Suction pumps. Local Coverage Article No. A52519. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdication A. Hingham, MA: NHIC; effective October 1, 2015.
  4. NHIC, Corp. Suction pumps. Local Coverage Determination No. L33612. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised October 1, 2015.
  5. Thompson L. Suctioning adults with an artificial airway: A systematic review. Systematic Review; 9. Adelaide, SA: Joanna Briggs Institute for Evidence Based Nursing and Midwifery; 2000.
  6. Woollons S. Ambulatory suction equipment for home use. Prof Nur. 1996;11(6):373-374, 376.