General Surgery Coding Alert

Reviewed on May 20, 2015
  General surgeons usually perform a tracheostomy (trach) for one of two reasons: the patient requires an emergency trach because of an airway obstruction or a planned trach is performed on a patient who can no longer tolerate intubation, says Marcella Bucknam, CPC, billing and compliance manager for the department of surgery at the University of Nebraska in Omaha.
 
Surgeons will not keep patients intubated for much longer than 10 days, Bucknam says. Therefore, if the patient still is not able to breathe without assistance, a tracheostomy will be performed.
 
Three CPT codes describe most tracheostomy and trach-related codes performed by general surgeons: 31502 (tracheotomy tube change prior to establishment of fistula tract; 1.00 total relative value units [RVUs]); 31600 (tracheostomy, planned [separate procedure]; 11.49 total RVUs) and 31603 (tracheostomy, emergency procedure; transtracheal; 6.46 total RVUs). Code 31500 (intubation, endotracheal, emergency procedure) is used to report a successful endotracheal intubation.
 
Although selecting the correct code is not difficult, there are several important factors to consider, such as global periods and separate procedures, that often complicate billing for these services.
E/M Day After Tracheotomy Payable  
Some surgeons do not bill follow-up E/M visits related to the tracheostomy because they assume there is a global period and, therefore, the visits are nonpayable. This is untrue for Medicare patients. According to the Center for Medicare and Medicaid Services (CMS) fee schedule, all three above-listed trach procedures include zero global days -- which means any visit or service performed one or more days after surgery on a Medicare patient is payable separately. Some commercial payers, however, do impose a 15-day global period on 31600 and 31601.
 
Trach Tube Changes and Fistula Tracts  
Trach placement involves a fistula tract from the skin of the anterior neck to the trachea. If the trach tube must be changed before the tract is fully established (usually after about seven days), report 31502.
 
This is the only time a trach tube change can be separately billed. There is no CPT code for a trach tube change performed after a fistula tract has been established. Any tube changes after the tract is established cannot be billed and become a component of the appropriate E/M service billed for the visit. If the tube change is documented, however, it may support a higher level of medical decision-making -- which in turn may result in a higher E/M level.
 
Furthermore, if the trach tube is changed during the global period of another procedure, it may provide medical necessity for a separate E/M service that otherwise would [...]