Otolaryngology Coding Alert

Question: When my otolaryngologist changes and/or removes a trach, how should I report the service?

Louisiana Subscriber

Answer: You should choose the code based on whether the otolaryngologist performs the tracheostomy tube change before or after the fistula tract is established. If the otolaryngologist changes the tube prior to the fistula's establishment, you should report 31502 (Tracheotomy tube change prior to establishment of fistula tract). No specific time parameter exists in determining when the fistula tract is definitely established. But experts agree that the trach is usually established within one week of the tracheotomy. Therefore, you should report 31502 for trach tube changes within approximately a week of the original tracheotomy or prior to the establishment of the fistula tract.

On the other hand, CPT does not contain a code for trach changes or removals performed after the fistula is established. Therefore, you should consider postfistula trach changes a component of the E/M. If the otolaryngologist changes or replaces the tube in the operating room under anesthesia with no other procedure, use 92502 (Otolaryngologic examination under general anesthesia).

For changes that do not require general anesthesia, such as in-office changes, you may include the service in the E/M service, such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ). The otolaryngologist should accurately document the entire E/M service and indicate the medical necessity for changing the trach. In some instances, proper documentation could result in a higher level of medical decision-making (because there is more risk and more complexity) which could affect the level of the E/M service.

Answers to You Be the Coder and Reader Questions provided by Rhonda Buckholtz, CPC, practice manager at Crawford and Fitch Ear, Nose and Throat in Franklin, Pa.; 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.; Tara R. Ritter, appeals coordinator for American Physician Services, which serves multiple ENT, allergy, sinus, and head and neck practices in metro Atlanta.