Otolaryngology Coding Alert

First, differentiate tracheotomy from tracheostomy.

When your otolaryngologist is called upon to perform a tracheostomy procedure, your coding will change dramatically depending on the specifics of the service they perform, how old the patient is, whether it was an emergency, and several other details.

But your first step when looking at trach charts is to differentiate the terminology so you understand what you’re reading when you review the op note. The cut that the otolaryngologist makes to open a patient’s windpipe is called a tracheotomy, while the opening itself is referred to as a tracheostomy. Although that “s” in the middle may seem insignificant, that’s what you’ll want to look for in terms of the actual surgical procedure.

When it comes to coding tracheostomy procedures, you should know a few key facts before you attempt to code a chart for this service. Check out the following three frequently-asked questions, along with the answers that will help you get a firm grasp on how to report tracheostomies.

Understand How to Code Newborn Trachs

Question 1: How should you code a tracheostomy on an infant?

Answer 1: The answer depends on whether the trach procedure was planned or not. If your physician performs a planned tracheostomy on a patient younger than 24 months old, you should report 31601 (Tracheostomy, planned (separate procedure); younger than 2 years).

If, however, the physician performs an emergency tracheostomy, you should instead report 31603 (Tracheostomy, emergency procedure; transtracheal). This code applies to patients of any age who undergo emergent tracheostomies.

Keep in mind that 31601 does include the terminology “separate procedure” in the descriptor. Therefore, if the trach is a component of a more extensive service, you cannot report 31601 separately. It will likely be bundled into the other, more extensive procedures.

Identify More Extensive Procedures

Question 2: During a planned tracheostomy on an adult patient, the doctor performs a tracheal bronchoscopy through the tracheostomy incision and cleans the trachea, as well as the right and left main bronchi, to improve ventilation. Which codes should you report?

Answer 2: The code for the tracheostomy is 31600 (Tracheostomy, planned (separate procedure)) and the code for a diagnostic bronchoscopy is 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)), says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey. “But 31622 is performed by putting the bronchoscope through the mouth, down to the lungs. In this case, the physician is putting the endoscope through the trach incision and looking at the lungs. There is another code, 31615 [Tracheobronchoscopy through established tracheostomy incision], which more accurately defines what is actually taking place. However, since a planned tracheostomy is a separate procedure, you may not be able to report a tracheobronchoscopy [31615] together with a planned tracheostomy [31600].”

Answer Urgency Question to Evaluate Emergency Tracheostomies

Question: Another physician calls your ENT provider and asks them to perform a tracheostomy the same day. Does that qualify as an “emergency” procedure?

Answer: Not necessarily. CPT^® makes a primary distinction between planned and emergency tracheostomies, and therefore you must determine which of these conditions best describes the procedure when selecting a code.

To qualify as an emergency service, check whether the patient would be immediately imperiled without the trach being performed. In other words, the patient’s airway is so compromised that they are already obstructed or may obstruct at any moment.

Use common sense: Just because the ENT sees a patient and decides to perform a tracheostomy that same day doesn’t mean you have an emergency. Rather, an emergency tracheostomy must occur because of an immediate, life-threatening situation.

“The ENT must document the urgency associated with the airway obstruction in order to support the emergent nature of a tracheostomy,” Cobuzzi says. “Without documenting that the patient’s well-being is in peril if they don’t perform a tracheostomy immediately, an emergency trach may not be coded and be billed.”

As long as the documentation supports the fact that the patient’s well-being is dependent on opening up the airway immediately, you should report such emergency procedures with either 31603 or 31605 (Tracheostomy, emergency procedure; cricothyroid membrane). These two procedures differ according to the location at which the surgeon makes their incision.

Your most likely choice: The incision for transtracheal tracheostomy (31603) occurs in the trachea itself, usually between the second and third rings. This is the more typical procedure that ENT surgeons will use.

The surgical cricothyroid tracheostomy (31605) involves an incision in the cricothyroid membrane, at a palpable landmark that is used to identify the junction of the larynx and the trachea, Cobuzzi notes. “The incision in the skin is placed 1-2 cm away from the cricoid, often referred to as the sternal notch.” Although easier to perform than 31603, 31605 puts the vocal cords at risk of injury and is therefore less common. The only way to differentiate between these services is by reviewing the op notes thoroughly and determining where the surgery occurred. After getting that information from the procedure notes, you’ll be able to select the most accurate code.