Medicare Compliance & Reimbursement

For in-office tracheostomy tube changes, you won't be able to report a separate service, but good news: you may be able to claim the cost of supplies. Also, you can report tube changes in the OR, although it will mean more work for you.

Highlight these five tips, and your trach tube change claims will avoid common pitfalls.

For trach tube changes, you've got one CPT code:

31502 (Tracheotomy tube change prior to establishment of fistula tract).

Rule: You should report this only when your physician removes the indwelling tube and replaces it before the patient has had sufficient healing time to allow a fistula tract to form. In other words, you should report 31502 only when the otolaryngologist changes a tracheostomy tube before the fistula tract has become established or healed -- "usually within two weeks of the tracheostomy," says Karla M. Westerfield, COPM, business manager of the Southeast Wyoming Ear, Nose & Throat Clinic in Cheyenne.

Pitfall: 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. He must document it.

"The establishment of the fistula tract varies from patient to patient, and the physician will determine it in his documentation," Westerfield says. Making sure the fistula tract is healed matters, because changing the tube when the tract is immature is considerably more difficult than changing a tube after the tract has healed.

Unlike most tracheostomy codes -- which have a zero-day global period -- 31610 (Tracheostomy, fenestration procedure with skin flaps) includes a 90-day global period. This means that you cannot bill for related services (including trach tube changes) within the 90-day global period of 31610, says Ginny McManus, billing manager for Berger Henry ENT Specialty Group in Norristown, Pa.

Exception: "If the patient has chronic obstructive pulmonary disease (COPD) and requires a trach due to longterm respirator dependency and exhibits bleeding, swelling, or infection of the stoma, the physician can't treat these conditions in the office, so the physician takes the patient to the operating room." In this case, you may report 31899 (Unlisted procedure, trachea, bronchi) appended with modifier 78 (Unplanned return to the operating/ procedure room by the same physician following initial procedure for a related procedure during the postoperative period), Westerfield says.

Note: See the information on the next page for complete information on 31899.

Tip 3: Established Tract + Office Procedure = E/M Service, For trach tube changes in the office, nursing home, or bedside after the fistula tract has healed, you cannot report a separate procedure code. "You should include the trach change in the E/M code," McManus says.

Advantage: You may, however, consider the trach change as a factor when deciding on an appropriate-level E/M service for the encounter. For instance, assuming your physician documents the history and exam sufficiently and demonstrates a high level of medical necessity, the trach change could increase the level of the medical decision making (MDM) -- and thus assist in increasing the E/M level overall.

Heads up: You'll 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).

You may be able to recoup the expense of tube change supplies (when provided by the physician) using A4629 (Tracheostomy care kit for established tracheostomy), but this will depend on where the change takes place, as well as your payer's guidelines.

Pitfall: Code A4629 is for office only. You should report A4629 only if the physician performs the tube change in her office, using supplies that she provides and paid for as an office supply. If the physician provides care in another setting, such as a hospital or nursing home, the facility will charge for the supplies. In other words, the facility was already paid for the tracheostomy care kit.

You need a DME provider number for Medicare. You cannot report A4629 to your Medicare Administrative Contractors (MAC) unless you have a durable medical equipment (DME) number and you have to submit the claim to the Durable Medical Equipment Regional Center (DMERC) MAC.

Private payers may not stipulate this DMERC requirement, but for private payers with prescription plans, you may need to provide a prescription to the patient to report A4629. Even though you may not agree, some private payers may consider the site of service differential (the higher reimbursement in the office as compared to in a facility) sufficient to pay for the supplies.

When circumstances dictate that the physician must provide a post-fistula trach tube change in the operating room with the patient under anesthesia, your best code choice is unlisted procedure code 31899.

If the physician must perform a bronchoscopy (31622, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]) at the same time as the tube change, you may report the bronchoscopy separately.

Best bet: 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.