HCPCS code A4628 – Oropharyngeal suction catheter

Key takeaways

HCPCS Code A4628 describes an oral and/or oropharyngeal suction catheter for home patients who can’t clear mouth or throat secretions on their own.

Claims go to the DME MAC, not the Part B MAC, and the billing entity must be an enrolled DMEPOS supplier.

The Suction Pumps LCD denies more than 3 A4628 catheters per week as not reasonable and necessary. A written order must support the quantity.

Pabau’s claims management software pre-fills each claim from the patient record and holds back any claim that is missing required details.

HCPCS Code A4628: Definition and official descriptor

HCPCS Code A4628 is the Level II supply code for an oral and/or oropharyngeal suction catheter. It’s billed per catheter for home use under a written order. CMS policy article A52519 describes it as a short, usually rigid plastic catheter of durable construction. A Yankauer-style tip is the most familiar example.

The Centers for Medicare and Medicaid Services (CMS) maintains the HCPCS Level II code set and updates the official descriptors each year. A4628 sits in the A4206-A8004 range for medical and surgical supplies.

The table below summarizes the billing reference data a coder or DME supplier needs before submitting a claim.

What A4628 covers and what it doesn’t

A4628 covers an oral or oropharyngeal suction catheter used to clear secretions from the mouth and throat. Rigid Yankauer-style tips are the product most often billed under it. The catheter must be supplied for home use.

Two settings fall outside the code. During an acute hospital stay, the supply is bundled into the facility’s DRG payment. In a nursing facility (POS 31 or 32), Medicare denies it as noncovered, because DME items are statutorily excluded from payment there.

Use the table below to confirm whether a product belongs under A4628 or needs a different code.

Clinical context: When is A4628 used?

A4628 is used when a patient can’t clear oral or oropharyngeal secretions independently and needs suctioning at home. LCD L33612 bases coverage on that condition, not on a list of diagnosis codes. Policy article A52519 specifies no ICD-10 requirement for A4628.

Typical patients include people with a tracheostomy, dysphagia from a neurological condition, or a history of aspiration. The treating physician documents the inability to clear secretions in the medical record before the supplier bills.

Examples of diagnoses a physician may document alongside that finding include:

• J95.00-J95.09: complications of tracheostomy
• R09.02: hypoxemia, where the notes describe a need for secretion management
• I69.391: dysphagia following cerebral infarction
• J69.0: pneumonitis due to inhalation of food and vomit (aspiration history)
• J96.0x-J96.9x: respiratory failure requiring home airway support
• R13.10-R13.19: dysphagia, unspecified or by phase

None of these codes secures coverage on its own. The record has to show the functional finding the LCD describes. Some contractors also publish extra guidance, so check your DME MAC’s current LCD before billing.

A4628 vs. related HCPCS codes

A4628 sits among respiratory and airway supply codes that billers often mix up. Its closest neighbor is A4624, the long, flexible tracheal suction catheter. The closed-system tracheal version bills as A4605.

Choosing the wrong code leads to a denial or a medical necessity mismatch that delays payment. Use the comparison table below to pick the right code for each supply.

Medicare reimbursement for HCPCS Code A4628

Medicare reimbursement for HCPCS Code A4628 is published in the CMS DMEPOS fee schedule, which CMS updates each January and lists by state. Rates change and vary by geography, so this guide doesn’t state a dollar amount.

To find the current allowable for your state:

1. Open the DMEPOS fee schedule page on the CMS website.
2. Download the fee schedule file for the current year and quarter.
3. Open the file and filter the HCPCS column for A4628.
4. Read the fee in the column for your state.
5. Treat that figure as the allowed amount before coinsurance and deductible.

Medicare Part B typically covers 80% of the approved amount after the annual deductible. The beneficiary pays the remaining 20% coinsurance unless a supplemental policy covers it.

Quantity is capped as well. LCD L33612 denies more than 3 A4628 catheters per week as not reasonable and necessary. Neither the LCD nor policy article A52519 sets a prior authorization threshold for A4628.

Documentation requirements for A4628 claims

Missing or incomplete documentation is a leading cause of A4628 denials. Good medical billing compliance means assembling the full documentation package before the supplier ships the product, not after the claim goes out.

Required documentation for a compliant A4628 claim:

• Standard written order (SWO): a signed, dated order from the treating practitioner naming the item and the quantity. It must be on file before the claim is submitted, and it has to support the quantity billed.
• Medical records: chart notes showing that the patient can’t clear oral or oropharyngeal secretions independently, plus the clinical history behind the order. A diagnosis code alone doesn’t meet the LCD criteria.
• No Certificate of Medical Necessity: CMS retired CMNs for dates of service from January 1, 2023, so none is filed with an A4628 claim.
• Proof of delivery: the delivery date and quantity dispensed, signed by the beneficiary or their designee.
• Supplier documentation: evidence that the supplier is enrolled in Medicare as a DMEPOS supplier and holds the required accreditation.

Keep all documentation for at least seven years from the date of service, in line with the CMS record-retention rule for DMEPOS suppliers.

How to bill A4628: Submission requirements

A4628 claims go to the DME MAC, not the physician’s Part B MAC. The billing entity must be an enrolled DMEPOS supplier, unless the practice is also enrolled as one. Getting this right avoids the most common routing error on A4628 claims.

Every A4628 line has to clear five checks before it goes out, and each one maps to a denial covered later in this guide.

Submission checklist for HCPCS Code A4628:

• Claim form: CMS-1500 (paper) or 837P (electronic). Most DME MACs require electronic submission once a supplier passes a minimum claims volume.
• Place of service: code 12 (Home) for supplies delivered to the beneficiary’s residence. Supplies delivered to a nursing facility (POS 31 or 32) are denied as noncovered.
• Units of service: one unit equals one catheter. Bill the quantity dispensed and documented in the delivery record, up to 3 per week.
• Modifiers: check the applicable LCD and policy article for required modifiers. None is specified for A4628 beyond standard claim modifiers such as GA when an ABN is on file.
• Date of service: use the date of delivery, not the date the order was written.
• Diagnosis pointer: point the A4628 line to the diagnosis documented in the record. A line without a valid diagnosis pointer is rejected before processing.

Use the AAPC HCPCS code reference or the PGM Billing HCPCS lookup to confirm the current descriptor and coding notes before finalizing the claim. Dedicated claims software for billers runs the modifier and diagnosis-pointer checks automatically, so errors surface before the 837P is generated.

Common A4628 claim denial reasons and how to fix them

A4628 denials cluster around five failure points. They are undocumented coverage criteria, a missing order, quantity over the weekly cap, a nursing facility delivery, and wrong payer routing. The table below maps each pattern to its typical CARC code and the fix.

For the full CARC list and appeal workflows, see our denial codes reference and these denial management strategies.

Coding tips to avoid HCPCS Code A4628 billing errors

Most A4628 billing errors can be prevented at order intake, before the supply ships. These tips cover points that standard coding references rarely spell out.

• Cross-walk from the product catalog number. Don’t assume a product labeled “Yankauer suction catheter” maps to A4628. Check the manufacturer’s catalog number against the PDAC product classification list first, because billing an unverified product creates audit exposure.
• Avoid unbundling with ventilator supplies. When a patient is on a home ventilator, the suction catheter may fall under the ventilator supply rules rather than billing separately as A4628. Review your DME MAC’s ventilator policy before billing both on the same claim.
• Use the KX modifier only where a policy requires it. KX certifies that the documentation on file meets an LCD’s requirements. Neither LCD L33612 nor policy article A52519 calls for it on A4628, so don’t add it by habit.
• Maintain an audit-ready documentation log. For each A4628 order, log the order date, quantity dispensed, delivery date, and weekly running total in a format you can pull on request. A spreadsheet with scanned orders meets the minimum standard, while software that links documents to the claim line cuts retrieval time.
• Reconcile the delivered quantity every week. Bill only what was delivered and signed for, and never more than 3 catheters per week. Billing the cap when fewer units were dispensed is a billing error, and post-payment audits look for it.

How Pabau keeps A4628 supply claims clean

Many suppliers keep orders in a spreadsheet and claims in a separate portal. A missing order or an over-cap quantity then surfaces only when the denial arrives. By then the catheters have shipped, and the fix is an appeal.

Pabau, the practice management platform we build, keeps insurer details on the patient record and pre-fills each claim from it. Background checks flag missing details, and the claim can’t be sent until they’re fixed. In the US, claims go out through Claim.MD, with real-time eligibility checks and ERA posting.

The outcome is fewer A4628 denials to chase, and every claim’s status in one dashboard, from pending to paid.

Manage HCPCS supply billing without the paperwork pile-up

Pabau pre-fills each claim from the patient record and holds back any claim missing required details, so your DMEPOS supply claims go out complete. See it in action.

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Conclusion

A4628 claims rarely fail on the code itself. They fail on the paperwork around it. The order doesn’t support the quantity, the notes don’t show the patient can’t clear secretions, or the catheters went to a nursing facility.

Build the weekly cap and the order check into intake, and you avoid most of those denials. The trade-off is a few minutes per order up front instead of an appeal months later.

Book a demo to see how Pabau checks supply claims for missing details before they reach the DME MAC.

Continue your research

Need a clean claim checklist for supply codes? Submitting a clean claim covers the elements every supply claim needs before it reaches the MAC queue.

Troubleshooting a batch of denied DME claims? Denial management strategies walks through the appeal workflow for CARC-coded rejections.

Want the full CARC reference for supply code rejections? Denial codes in medical billing maps the most common adjustment reason codes to corrective actions.

Looking up another supply code? HCPCS codes gathers our billing guides for Level II supply, drug, and equipment codes.

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