Otolaryngology Coding Alert

When reporting post-tracheostomy care, be sure to consider coding for follow-up care, trach changes and potential further procedures to ensure appropriate reimbursement for all services the otolaryngologist performs.

After an otolaryngologist performs a tracheostomy, several postsurgery issues emerge, such as reporting follow-up care, trach changes and additional procedures. To find out if you can bill related post-tracheostomy services and procedures, answer three questions.

(For advice on selecting the appropriate tracheostomy code [31600-31610], see page 1 of the January 2003 Otolaryngology Coding Alert .)

1. Does the Patient's Carrier Include Follow-Up Care?

Although the 2003 National Physician Fee Schedule Relative Value File assigns a zero-day global period to planned tracheostomy codes 31600 (Tracheostomy, planned [separate procedure]) and 31601 ( under two years), many private payers assign a 15-day global to these codes. Consequently, you should separately report any follow-up services, including E/M visits (99231-99233, Subsequent hospital care), for Medicare patients starting the day after surgery (day 1), says Richard A. Chole, MD, PhD, Lindburg Professor and head of the department of otolaryngology at Washington University School of Medicine in St. Louis. "We follow Medicare's global surgical days (and so do most other payers in our area)."

For third-party carriers, you should follow Medicare's policy, says 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. That way, you will not lose reimbursement for services to which your practice is entitled. If the carrier denies the claim, you should challenge the plan with a letter stating Medicare's policy of a zero-day global.

Medicare designates a zero-day global for 31603 (Tracheostomy, emergency procedure; transtracheal) and 31605 ( cricothyroid membrane). Coding experts do not cite a problem with commercial payers imposing a different global period for these codes.

They do, however, report conflicting periods for 31610(Tracheostomy, fenestration procedure with skin flaps). Medicare imposes a 90-day global period for 31610. On the other hand, many private payers include a shorter surgical package of 45 postoperative days for this code. Because of this discrepancy, you can start reporting services at day 46 to determine if the payer will allow those services and, if not, write them off when you receive the evaluation of benefits (EOB), Cobuzzi suggests. "Collect data on your payer's different global periods and track them based on the payments you get on your EOBs."

2. How Should You Code a Trach Change?

CPT contains only one code for trach tube changes:

When an otolaryngologist changes a tracheostomy tube before the fistula tract is fully established, you should report 31502. Although no specific time period exists to determine the tract's establishment, the tract is usually established within one postoperative week. Changing the tube when the tract is immature is more difficult than when the tract is fully established.

CPT does not contain a code for changing the trach tube after the tract matures. Therefore, you should include the change as part of an E/M service provided to the patient at the visit, Chole says. You cannot report the trach change separately, and it is therefore included in the E/M. If the physician clearly documents the E/M encounter and the medical decision-making that led him or her to change the trach tube, and the medical necessity supports the tube change, the documentation may support a higher-level E/M, Cobuzzi notes. If the otolaryngologist performs the procedure in the office, make sure you also bill for the supply of the materials, such as A4622 (Tracheostomy or laryngectomy tube), Chole says, and link the E/M service to V55.0 (Attention to artificial openings; tracheostomy) and the related condition, such as respiratory failure (518.81, Acute respiratory failure).

3.Does the Patient Require Further Procedures?

Depending on whether the tracheostomy is for long- or short-term use, the otolaryngologist may need to perform other procedures. For instance, patients who require long-term trachs may require additional procedures due to complications, such as stenosis (519.02, Mechanical complication of tracheostomy). If the physician repairs the opening without flap rotation, you should assign 31613 (Tracheostoma revision; simple, without flap rotation). For more complicated revisions that require flap rotation, report 31614 ( complex, with flap rotation).

Some patients whose breathing problems resolve may no longer require the tracheostomy. If the otolaryngologist closes the hole and removes the fistula that supported the airway, you should bill 31820 (Surgical closure tracheostomy or fistula; without plastic repair). If the patient requires plastic surgery to close the stoma, report 31825 ( with plastic repair).

Be careful. Coders sometimes misuse 31720 (Catheter aspiration [separate procedure]; nasotracheal), says Laura Siniscalchi, RHIA, CCS, CCS-P, CPC, senior consultant for Deloitte & Touche in Boston. "Code 31720 involves aspiration through the nasal area and should not be used for the suctioning of a tracheostomy patient."

Rachel O'Niell, RHIA, CCS-P, coding supervisor for the department of otolaryngology at Washington University School of Medicine in St. Louis, also contributed to this article.