Otolaryngology Coding Alert

Don’t forget to change your coding tactic for OR procedures.

As an otolaryngology coder, you know that you can’t report a separate service when your physician performs an in-office tracheostomy tube change. You can, however, sometimes be reimbursed for supplies. Keep five things in mind when filing these claims and discover whether the service merits extra pay. 

Tip 1: Choose 31502 When Fistula Tract Is Not Established

CPT® 2014 includes a single code for trach tube changes: 31502 (Tracheotomy tube change prior to establishment of fistula tract). The current Medicare pay rate is $36.18 for in-office service, based on the national conversion factor of $35.8228. 

Rule: Only report 31502 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, 31502 only applies when the otolaryngologist changes a tracheostomy tube before the fistula tract has become established or healed — usually within two weeks of the tracheostomy. Before using 31502, verify that the documentation reflects that the fistula has not fully established, says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. 

Reasoning: 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.

Pitfall: CPT® does not provide specific guidelines on when the fistula tract becomes “established,” probably because establishment varies from patient to patient. That means you should rely on your physician’s clinical judgment and documentation to determine the status of healing. 

Tip 2: Adhere to 90-Day Global Rules for 31610

Unlike most tracheostomy codes — which have a zero-day global period — 31610 (Tracheostomy, fenestration procedure with skin flaps) includes a 90-day global period within the Medicare fee schedule. This means that you cannot bill for related services (including trach tube changes) within the 90-day global period of 31610. “Remember that private payer global periods aren’t necessarily the same as Medicare global periods,” Cobuzzi says. Private payers might not publish their global periods, so gather whatever information you can from your local representative. 

Exception: If the patient has chronic obstructive pulmonary disease (COPD, 496 [Chronic airway obstruction, not elsewhere classified]) and requires a trach due to long-term respirator dependency and exhibits bleeding, swelling, or infection of the stoma, the physician can’t treat these conditions in the office. The physician must take the patient to the operating room for treatment. In this case, you may report 31899 (Unlisted procedure, trachea, bronchi) if the fistula tract is established or 31502 if the fistula tract is not established. Append 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) to the surgical code.

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. 

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).

Tip 4: Remember to Recoup Supply Reimbursement 

You may be able to recoup the expense of tube change supplies (when provided by the physician in the office) 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.

Pay attention: Code A4629 is for office procedures 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. 

Tip 5: For OR Replacement, Use 31899

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 unlisted procedure code 31899. If the ENT must perform a bronchoscopy at the same time as the tube change, you may report the bronchoscopy separately with 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]). 

Best bet: You should submit 31899 with a cover letter explaining the procedure. For instance, if the change required anesthesia due to extenuating circumstances (such as a restless child), make sure your documentation demonstrates medical necessity to support the performed procedure in the operating room under anesthesia.