General Surgery Coding Alert

Trach Tips:

Coding Strategies To Optimize Reimbursement

Published on Wed Aug 01, 2001 Updated on Wed Aug 01, 2001

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 be included in the other procedure's global period, Bucknam says. For example, a trauma patient who requires a splenectomy (38100, splenectomy; total [separate procedure]) also needs a tracheostomy because the airway is obstructed. According to the CMS fee schedule, 38100 has a 90-day global period, which means that any E/M performed during that time is already included in the fee paid for 38100 and will not be paid separately. But changing the trach tube during a visit may provide medical necessity to bill a separate E/M service because it indicates the E/M was unrelated to the splenectomy. In this situation, modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) should be appended to the appropriate E/M service.

When Separate Procedures Aren't Separate

A planned or elective trach is a separate procedure"" that usually should not be billed if performed at the same time as a more extensive related procedure such as a thyroidectomy (60240 thyroidectomy total or complete) or parathyroidectomy (60500 parathyroidectomy or exploration of parathyroid[s]). If the surgeon is treating the patient for another problem in a different anatomic site (i.e. an abdominal or vascular procedure) however 31600 may be separately billed.

Other Tracheostomy Codes

Planned tracheostomies on children under age two which are difficult and are typically performed by pediatric surgeons should be reported using 31601 (tracheostomy planned [separate procedure]; under two years).

Code 31605 (tracheostomy emergency procedure; cricothyroid membrane) is rarely used even though it is a ""simpler"" procedure than a normal emergency trach (31603) because it involves a lot of risk says M. Trayser Dunaway MD FACS a general surgeon in Camden S.C.

""Going through the cricothyroid only happens in an airplane at 30 000 feet when all you have is a penknife and a hollowed-out pen for a tube "" Dunaway says only half-jokingly. ""In the emergency department these trachs are rare.""

The two forms of tracheostomy differ by location. Although the cricothyroid trach is easier to perform it puts the vocal cords at risk of injury which is not the case with the standard ""transtracheal"" trach.