Otolaryngology Coding Alert
Start With 709.2 for Visit Due to Trach Site Pain
Question: A patient came to our office for evaluation of her trach tube with pain at the trach site. The physician used the diagnosis of 519.02 (Mechanical complication of tracheostomy). This was denied by the payer as an invalid diagnosis. What would be the correct diagnosis?
New Mexico Subscriber
Answer: The scarring of the incision is what’s causing the patient’s pain, so begin your diagnosis search with “scar pain.” That leads you to several options:
Also note: The ICD-9 index states, “Pain due to (presence of) any device, implant, or graft classifiable to 996.0-996.5 - see Complications, due to.” Because of this, diagnosis 519.09 (Other tracheostomy complications) could also be appropriate.
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