General Surgery Coding Alert

Question: A patient underwent tracheostomy one week ago. A week later, the physician had difficulties oxygenating the patient and had to re-intubate her. Should I report 31502 or 31899 for the tube change?

Colorado Subscriber

Answer: You should report 31502 (Tracheotomy tube change prior to establishment of fistula tract) only when the surgeon changes a tracheostomy tube before the fistula tract has become established. In other words, if the physician removes the indwelling tube and replaces it before the patient has had sufficient healing time to allow a fistula tract to form, you would claim 31502.

CPT does not provide specific guidelines on when the fistula tract becomes "established," and you should rely on your physician's clinical judgment to determine this. As a general rule, however, the tract is usually established within seven to 10 postoperative days of the tracheostomy. In your case, 31502 is probably the best code choice.

When circumstances dictate that the surgeon must provide a post-fistula tracheostomy tube change in the operating room with the patient under anesthesia, your best code choice is 31899 (Unlisted procedure, trachea, bronchi).

You should submit 31899 with a cover letter explaining the procedure. For instance, if the change required anesthesia due to extenuating circumstances (for instance, a restless child), make sure your documentation demonstrates medical necessity to support performing the procedure in the operating room under anesthesia.

For tracheostomy tube changes in the office, nursing home or bedside after the fistula tract has healed, you cannot report a separate procedure code. You may, however, consider the tracheostomy change as a factor when deciding on an appropriate-level E/M service for the encounter.

Tip: The physician's notes must establish medical necessity for the tracheostomy change -- and must demonstrate the elements of medical decision-making that determined the need for the change -- if you are going to consider the tracheostomy change when determining the E/M service level. You-ll also want to link any relevant diagnoses to the E/M service code, including V55.0 (Attention to artificial openings; tracheostomy) and the related condition, such as respiratory failure (518.81, Acute respiratory failure).