Otolaryngology Coding Alert

Strategy: Try 31899 for OR change under general anesthesia

Even though no code describes a postfistula tube change, you can use an unlisted procedure code provided 31502 or an E/M code doesn't apply.

1. Count Prefistula Change as 31502

The simplest tracheostomy tube replacement coding option you have is 31502 (Tracheotomy tube change prior to establishment of fistula tract). But you can only use this code when the otolaryngologist performs the change prior to the patient's fistula tract being established" " says Dora A. Allen CPC coding coordinator at the three otolaryngologist University Surgical Associates in Louisville Ky.

Problem: No definitive time period exists for determining whether the tract has been established. "You really have to look at the otolaryngologist's wording" and the patient's recovery time Allen says.

If the otolaryngologist removes the indwelling tube and replaces it with a new one before the patient has had sufficient healing time to allow a fistula tract to form report 31502. Once the tract has formed reject the tracheotomy tube change code (31502).

Fistula's Formation Negs Specific Code

When 31502 no longer applies a new coding problem emerges. CPT doesn't contain a code for a postfistula change. For these procedures you should bill using one of the following methods.

2. Try 31899 for Replacement in OR

You may consider reporting 31899 (Unlisted procedure trachea bronchi) when an otolaryngologist changes a tracheostomy in the operating room (OR) under general anesthesia. "If the surgeon is just changing the tubing we use the unlisted code " says Allen. "ENTs often perform the change as additional care while a general surgeon is operating on the patient."

Example: A general surgeon performs a partial colectomy (44140 Colectomy partial; with anastomosis) on a patient. While the patient is under anesthesia the otolaryngologist changes the patient's tube.In this case you could code the trach change as 31899. The general surgeon would report 44140.

You would not need a co-surgery modifier on the claim. CPT intends modifier -62 (Two surgeons) for use only "when two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure." Because the colectomy and trach change are separate procedures each physician reports his own operation and code with no modifier.

Good news: Some insurers will reimburse 31899. "Payment depends on the carrier " Allen says. Medicare won't cover it.

"You won't get much for the OR trach change "Allen says. But payers will usually cover the procedure because of the anesthesia.

Tip: You should submit 31899 with a cover letter explaining the procedure as with all unlisted procedure code claims. If the change required anesthesia due to extenuating circumstances make sure you describe the details.

For instance two weeks after undergoing a tracheostomy a young child's tube requires changing. Due to the child's age and inability to remain still the otolaryngologist decides to perform the procedure under general anesthesia.

Best practice: The otolaryngologist clearly documents the patient's age and restlessness and why the patient needed general anesthesia. When you submit 31899 for the claim you attach a cover letter pointing out the general anesthesia's medical necessity and the operative note highlighting the supporting documentation.

3. Report In-Office/Bedside Change With E/M

 When an otolaryngologist changes a tracheostomy tube in the office or at bedside you shouldn't report any specific code for the procedure. "We include the change as part of the E/M service " says Melissa Pointer CPC billing manager for the department of otolaryngology at the University of Arkansas for Medical Sciences in Little Rock.

Encourage the otolaryngologist to clearly document the E/M encounter (such as 99212-99215 Office or other outpatient visit for the evaluation and management of an established patient ...) the medical decision-making that led him to change the trach tube and its medical necessity. "Clear documentation could affect the level of service " Pointer says.

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).

Consider Office 'A' Codes

You may also report HCPCS supply codes for the tracheostomy materials such as A4629 (Tracheostomy care kit for established tracheostomy).

Warning: Make sure you only bill the supply for in-office trach changes. Hospitals or home health centers such as a nursing facility will charge for the supply.

Example: An otolaryngologist changes a nursing facility patient's long-term tracheostomy using a trach care kit and documents an expanded problem focused interval history an expanded problem focused examination and medical decision making of moderate complexity. You would report the nursing facility (place of service code 32) encounter with 99312 (Subsequent nursing facility care per day for the evaluation and management of a new or established patient ...). The facility would bill A4629.

Be careful: Submit in-office supplies to private payers only. Medicare requires you to have a durable medical equipment (DME) number to bill A4629.