Otolaryngology Coding Alert

Reviewed on May 15, 2015

Post-fistula procedures may call for unlisted-procedure code

CPT contains just a single code for tracheostomy tube change: 31502. But 31502 won't fit the bill for most trach tubes your otolaryngologist replaces.

For in-office tube changes, you probably can't report a separate service--but you may be able to claim the cost of supplies. And you can report tube changes in the OR, although it will mean more work for the coder.

Timing Sets 31502 Apart

You should report 31502 (Tracheotomy tube change prior to establishment of fistula tract) only when the otolaryngologist changes a tracheostomy tube before the fistula tract has become established, says Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor. 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.

Rule of thumb: 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, Koopmann says. Changing the tube when the tract is immature is considerably more difficult than changing a tube after the tract has healed.

Learn more: For complete information on tracheostomy procedures, see page 81 of the November 2005 Otolaryngology Coding Alert.

90-Day Global Makes 31610 an Exception

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 unless the ENT must return 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 or Other Qualified Health Care Professional  following initial procedure for a related procedure during the postoperative period. See the information below for complete information on 31899.

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 may, however, consider the trach change as a factor when deciding on an appropriate-level E/M service for the encounter, says Melissa Pointer, CPC, billing manager for the department of otolaryngology at the University of Arkansas for Medical Sciences in Little Rock.

Remember: The physician's notes must establish medical necessity for the trach change--and must demonstrate the elements of medical decision-making that determined the need for the change--if you are going to consider the trach change when determining the E/M service level.

For example: 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).Diagnosis V55.0 will cross to Z43.0 (Encounter for attention to tracheostomy) under ICD-10. Diagnosis 518.81 will have multiple related options for ICD-10 coding. These will include:

• J96.00 – Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
• J96.01 – Acute respiratory failure with hypoxia 
• J96.02 – Acute respiratory failure with hypercapnia
• J96.90 – Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
• J96.91 – Respiratory failure, unspecified with hypoxia
• J96.92 – Respiratory failure, unspecified with hypercapnia.

Supply Reimbursement Is Possible

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.

Code A4629 is for office only: You should report A4629 only if the physician performs the tube change in her own office, using supplies that she provides. If the physician provides care in another setting, such as a hospital or nursing home, the facility will charge for the supplies.

You need a DME provider number for Medicare: You cannot report A4629 to Medicare payers unless you have a durable medical equipment (DME) number. Private payers may not stipulate this requirement, but for private payers with prescription plans, you may need to provide a prescription to the patient to report A4629.

31899 Is the Choice for OR Replacement

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

If the ENT must perform a bronchoscopy (31622, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure] at the same time as the tube change, you may report the bronchoscopy separately, Koopmann says.

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.

Get the whole story: For complete instructions on reporting unlisted-procedure codes, see -3 Tips Mean -Unlisted- Doesn't Have to Mean Unpaid- later in this issue.