Otolaryngology Coding Alert

Tip: Get clear documentation of the complaint.

According to coding guidelines, 31502 (Tracheotomy tube change prior to establishment of fistula tract) represents a change in a patient’s tracheostomy tube before the surgeon establishes a mature fistula tract. You don’t normally report 31502 for patients who have long-term, established tracheostomies. Instead, you report the work with an E/M code if a patient with an established tracheostomy has a trach tube change.

Dilemma: Do you know how to capture that work as part of an E/M service? If you’re not sure, keep reading for some expert advice that will have you coding with confidence.

Step 1: Pinpoint the Chief Complaint

The work of 31502 generally takes place within the first week of the patient’s tracheostomy tube being placed. There must be a reason for the change – otherwise, your physician wouldn’t be providing the service. Many possibilities exist, but check the encounter notes for references to conditions such as:

• J95.03 (Malfunction of tracheostomy stoma), which includes: 

          o Mechanical complication of tracheostomy stoma
          o Obstruction of tracheostomy airway
          o Tracheal stenosis due to tracheostomy

• J95.09 (Other tracheostomy complication), which includes pain, leakage, or other complications
• Z43.0 (Encounter for attention to tracheostomy).

Bottom line: “There must be some type of complaint that goes along with changing the tube, which is why your doctor is being asked to change it,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J. “That is your chief complaint.”

Step 2: Capture the History

Chances are, someone in your practice has seen this patient prior to the trach tube change. If so, Cobuzzi says you should be able to capture a history that’s at least extended problem focused, or EPF.

“The prior history often is a comprehensive one, from when the patient was first seen,” she says. “Then when your physician reviews it and notes remarkable changes, you still have a comprehensive history.”

Tip: The physician’s note should state either, “Reviewed history of (x date) and remarkable changes include …” or “Reviewed history of (x date) and there are no remarkable changes.”

The exam can then be either problem focused or expanded problem focused, depending on the medical necessity of the presenting problem which should drive the extent of your physician’s exam. The basic definitions (1995 exam) of these types of examinations are:

• Problem focused: a limited examination of the affected body area or organ system based on the 1995 exam guidelines or 1-5 bullets based on the 1997 Otolaryngology Specialty bulleted exam.
• Expanded problem focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) based on the 1995 exam guidelines or 6-12 bullets based on the 1997 Otolaryngology Specialty bulleted exam.

Step 3: Determine the Level of Decision-Making

The last factor in choosing the most appropriate E/M code is medical decision-making. Even though the patient might have had a trach tube change in the past, this particular trach tube problem is new.

“No new work-up is planned, so that’s 3 points toward your calculation,” Cobuzzi says. “No data will be reviewed and no other services will be ordered, so now you need to determine the risk.”

Evaluate it: This will be a minor procedure. If the patient does not have any identified risk factors, the risk is low. If there are identified risk factors, the risk is moderate.

Cobuzzi says identified risk factors that may be considered include chronic conditions that can increase the patient’s risk of an infection, the length of time the patient has been tracheostomy dependent, the frequency of needed tracheostomy changes, the patient’s propensity to bleed (and, therefore, risk of hemorrhage), among others.

Bottom line: The E/M service will be based on:

• The level of history you have
• Whether the change is complex or not
• The medical complexity (which in this case translates to medical necessity for the patient and the doctor).

Assuming your interval or new history is at least detailed or higher and the patient had identified risk factors for the tube change, then you can submit 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity). If the history was below a detailed (that is, EPF or PF) or if the procedure was a straightforward trach tube change for a patient with no identified risk factors, report the service with 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity).

Remember: “MDM (medical decision making) does not always have to be one of the three elements as long as the extent of the exam is appropriate for the medical necessity of the nature of the presenting problem,” Cobuzzi points out. “The problem that is created when MDM is not counted is when a more extensive exam than is medically appropriate for the presenting problem is performed.”