Otolaryngology Coding Alert

Answer Five Questions to Determine the Appropriate Trach Code

Published on Wed Jan 01, 2003

Reviewed on May 21, 2015

"To alleviate confusion concerning coding for tracheostomies, answer the following questions to guide you to the correct procedural code.

(For tips on reporting related post-tracheostomy procedures and services, see Resolve Post-Tracheostomy Billing Issues With Three Questions"" in next month's issue.)"

1. Is the Tracheostomy Planned or Is It an Emergency?

CPT lists four codes that describe tracheostomy with no additional procedures:

31600 Tracheostomy planned (separate procedure)

31601 younger than two years

31603 Tracheostomy emergency procedure; transtracheal

31605 cricothyroid membrane .

And one code for tracheostomies with skin flaps:

31610 Tracheostomy fenestration procedure with skin flaps.

The key difference between 31600-31601 and 31603-31605 are the terms "planned" and "emergency. You should choose between these code sets based on the events surrounding the tracheostomy. If the patient may obstruct sometime and the otolaryngologist schedules the procedure assign a planned tracheostomy (31600-31601) says Charles F. Koopmann MD MHSA professor and associate chairman of the department of otolaryngology physician billing director and a member of the faculty group practice at the University of Michigan in Ann Arbor. "If the patient's airway is so tenuous that the physician cannot postpone the tracheostomy report an emergency tracheostomy (31603-31605)."

The events surrounding the trach can often point you to the correct code set. For instance planned trachs (31600-31601) frequently occur after a patient has been intubated for a long period or requires long-term ventilatory support. The tracheostomy helps to suction secretions and increase air delivery to the lungs. The attending physician usually requests that an otolaryngologist perform the procedure. For these elective planned tracheostomies you should report 31600 or 31601.

On the other hand doctors perform emergency tracheostomies when a patient's airway is so compromised that he may obstruct at any moment. For example a patient presents with wheezing (786.07) which is quickly progressing to upper-airway obstruction. The otolaryngologist performs a tracheostomy. For emergent situations that require an opening of the windpipe assign 31603-31605.

Some coders question whether an emergency trach requires a dire situation or if a situation that requires a same-day tracheostomy qualifies as urgent. "Emergency tracheostomy is just what it says it is it is an emergent situation " says Barbara Cobuzzi MBA CPC CPC-H an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions a medical billing firm in Lakewood N.J.

Stedman's Medical Dictionary defines emergency as "an unexpected development or happening; a sudden need for action." "You cannot describe a set amount of time to define an emergency versus planned trach " Koopmann explains. An emergency trach instead requires a sudden need for action due to the condition of the patient's airway.

For instance an adult patient has an abscess (e.g. 42300* Drainage of abscess; parotid simple) and stridor (786.1). The patient's airway may obstruct in a day or two. The otolaryngologist adds the patient to the operating-room schedule. You should report the tracheostomy as a planned procedure because the patient's condition did not require immediate action.

If the patient's condition deteriorates while he is waiting for the trach however the otolaryngologist may perform an emergency trach. For instance the patient in the above example is scheduled for a planned trach on Tuesday. On Monday his condition rapidly deteriorates and his airway starts to obstruct. He is rushed to the operating room where the otolaryngologist performs a tracheostomy. You should report an emergency trach. "The patient's condition started to go downhill and the otolaryngologist could no longer postpone the trach " Koopmann says.

In addition the location can aid coders in determining whether the tracheostomy is planned or emergent. "A tracheostomy performed in the operating room is usually planned whereas a trach performed in the emergency department or at bedside is typically emergent " says Laura Siniscalchi RHIA CCS CCS-P CPC senior consultant for Deloitte & Touche in Boston.

Location isn't always a defining aspect Koopmann cautions. Otolaryngologists may perform elective (planned) trachs at a patient's bedside.

If the otolaryngologist uses skin flaps to create a permanent opening report 31610. Although the otolaryn-gologist plans this procedure this code does not follow the same terminology differences as 31600-31605.

2. Planned: Is the Trach a Separate Procedure?

Before reporting 31600-31601 in addition to another code you should determine whether the tracheostomy is a separate procedure. CPT uses "separate procedure" to identify procedures that physicians commonly perform as an integral part of another procedure. You should not report separate-procedure codes in addition to the code for the total surgery or service of which it is an integral part according to CPT 2003.

Because otolaryngologists commonly include a planned tracheostomy as an integral part in other surgeries such as laryngectomy (31360-31390) and large glossec-tomies (41140-41145) the definitions specify that you can report 31600-31601 only when the tracheostomy is a separate procedure. Therefore when a physician performs a routine tracheostomy with a larger operation such as laryngectomy and glossectomy tracheostomy is considered integral to the larger procedure. If a physician performs a planned trach at the same time as a code that is unrelated to the tracheostomy you should report both procedures Siniscalchi says. Therefore you should report 31600-31601 when the otolaryngologist performs a tracheostomy:

alone

or for a different reason than that prompting the primary procedure provided you append

modifier -59 (Distinct procedural service) to the trach code.

For example the patient with the abscess in the above situation requires a tracheostomy for ventilatory management. The reason for the trach is unrelated to the primary procedure draining of the abscess. Therefore you should report both procedures. For the abscess drainage assign 42300. For the planned tracheostomy use 31600 appended with modifier -59 to indicate that the trach occurred at a different site and for a different reason than the abscess drainage.

Make sure the documentation clearly shows the difference between the procedure and the tracheostomy Cobuzzi emphasizes.

3. Planned: Is the Patient Less Than 2 Years Old?

Despite the fact that planned tracheostomies on small children may require significantly more work than a trach for an adult 31601 now has fewer relative value units than 31600. You should report 31601 for a planned trach on a child who is less than two years old Siniscalchi points out. "Use 31600 for older children and adults."

You may append new modifier -63 (Procedure performed on infants less than 4 kg) to 31601 if the otolaryngologist performs the procedure on an infant. Code 31601 eventually should contain the extra physician work for performing the procedure on small children but that will still not apply to extreme cases such as infants. When an otolaryngologist performs the procedure on a neonate or infant up to a present body weight of 4 kilograms you may use modifier -63 to indicate the increased complexity and physician work associated with these patients. CPT does not designate 31601 as modifier -63 exempt as other codes such as 31520 (Laryngoscopy direct with or without tracheoscopy; diagnostic newborn) do.

4. Emergency: Where Is the Incision Made?

For emergency tracheostomies you should report 31603 or 31605 based on where the doctor makes the incision. For a transtracheal tracheostomy the otolaryn-gologist makes an incision into the trachea usually between the second and third rings.

A cricothyroidectomy involves a small incision into the lower larynx specifically in the cricothyroid membrane. Although the cricothyroid trach is easier to perform than the transtracheal trach otolaryngologists rarely perform it.

5. Is an Assistant Surgeon Necessary?

Of the five trach codes only code 31601 for the planned trach for children allows for a second assistant according to the 2015 National Physician Fee Schedule Relative Value File. The fee schedule assigns a 1 to 31600 31603 31605 and 31610 and a 2 to 31601. The 1 indicates that statutory payment restrictions apply to assistants at surgery for the procedure and the carrier may not pay for an assistant surgeon. A 2 means that payment restrictions do not apply and the payer may reimburse for an assistant. So carriers may pay for an assistant surgeon if extenuating circumstances such as the patient's age or size show why the additional physician's services are necessary. Good documentation will help get claims paid and should support your case in the event of an appeal."