Otolaryngology Coding Alert

Coding and billing for tracheostomies or related procedures can be confusing because many of the applicable codes represent separate procedures. Additionally, some trach-related services, such as trach tube changes, usually are not separately payable.

CPT lists six trach-related codes:

31502 tracheotomy tube change prior to establishment of fistula tract; 2.21 relative value units (RVUs)

31600 tracheostomy, planned (separate procedure); 6.26 RVUs

31601 ... under 2 years; 7.78 RVUs

31603 tracheostomy, emergency procedure; transtracheal; 6.94 RVUs

31605 ... cricothyroid membrane; 5.96 RVUs

31610 tracheostomy, fenestration procedure with skin flaps; 19.17 RVUs.

In addition, 31500 (intubation, endotracheal, emergency procedure), although not a tracheostomy procedure per se, is often performed prior to or with a number of the procedures listed above.

Note: According to Dorlands Medical Dictionary, a tracheostomy is defined as the creation of an opening in the anterior trachea for insertion of a tube to relieve upper airway obstruction and to facilitate ventilation. A tracheotomy is defined simply as incision of the trachea. Although most physicians and associated healthcare personnel use the terms interchangeably, some physicians distinguish between tracheotomy and tracheostomy as follows: A tracheotomy is used when the opening that is created is expected to be permanent or long-lasting; tracheostomy refers to a temporary opening.

Is the Trach Long- or Short-term?

Long-term tracheostomies for ventilation may be required by patients with multiple sclerosis, as well as some stroke patients or those with amyotrophic lateral sclerosis (ALS, or Lou Gehrigs disease). These and other chronic conditions may cause breathing difficulties.

In some cases, the otolaryngologist may use skin flaps to create a more permanent stoma, or opening. This more extensive procedure (31610) is the only tracheostomy with a 90-day global period.

More typically, however, the otolaryngologist will perform a planned tracheostomy that does not require the construction of a permanent stoma. Most elective tracheostomies are requested for patients who have been intubated for an extended time, or for those who may require long-term ventilatory support.

Patients with an infection or malignancy may also require a short-term tracheostomy. Initially their condition may have been treated with an endotracheal intubation (31500). After several weeks the otolaryngologist determines that the intubation tube needs to be pulled and a tracheostomy is performed to allow the patient to recuperate.

Children under age 2 may require planned tracheostomies for a variety of conditions, including sub-glottal stenosis, a benign laryngeal tumor or paralyzed vocal cords. Such cases are more difficult, and should be reported using 31601, which reimburses at a higher rate than a planned tracheostomy on an adult.

Emergency Tracheotomies

Emergency tracheotomies are coded differently than planned tracheostomies. A planned trach involves an intubated patient and a request to the otolaryngologist, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs editorial panel and executive committee. An urgent trach is a patient who presents with upper airway obstruction.

CPT lists two procedures performed in an emergency setting: transtracheal tracheostomy (31603) and cricothyroidotomy (31605). The main difference between these codes is the location of the tracheostomy. The surgical cricothyroidotomy involves an incision in the cricothyroid membrane. Although this procedure is simpler (and is assigned fewer RVUs) than a typical tracheostomy, it involves more risk, Eisenberg says.

The problem with doing cricothyroidotomies is that the vocal cords are located at the bottom of the thyroid cartilage. If you place a trach there, there is a risk of injury to vocal cords, as well as a risk of laryngeal stenosis, Eisenberg says (he notes that CPTs Relative Value Update Committee was not consulted when the values for 31605 were established).

Because of the risks and associated stress involved with this procedure, cricothyroidotomy is reserved for life-threatening situations when instant access is required. The incision for the more typical transtracheal tracheostomy, described in 31603, is in the trachea itself, usually between the second and third rings.

Note: Surgical cricothyroidotomy should not be confused with needle cricothyroidotomy, which involves injecting the patient with a large, 14-gauge needle. This procedure can sustain a patient for 45 minutes only.

Carriers Impose Conflicting Global Periods

Otolaryngologists often do not bill follow-up visits related to tracheostomies, in part because they may incorrectly view the procedure as serious enough to warrant a global period, and in part because many private carriers assign a 15-day global to some of these procedures. According to Medicodes Head and Neck Coding Illustrated, for instance, many private carriers assign a 15-day global to 31600 and 31601.

These globals do not apply to Medicare, which places a 0-day global period on 31600, 31601, 31603 and 31605. This means that any follow-up services, including E/M visits, are separately payable the day after the surgery (but only if the patient is covered by Medicare).

To further complicate matters, despite Medicares 90-day global period for 31610, many private carries impose only a 45-day global period on this procedure.

Because not all private payers follow the same global package guidelines, Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions in Lakewood, N.J., recommends assuming that 30600 and 30601 do not have a global period as per Medicare guidelines when billing these procedures to commercial carriers. If the carrier does impose a 15-day global and the claim is denied, it can be written off at that time, she says.

Separate Procedures Are Often Bundled

Because planned tracheostomy is a separate procedure, it is usually bundled with any other procedure performed during the same operative session.

For example, if a laryngectomy (31360-31390) is performed and the patient also requires a trach, 31600 should not be billed. The planned tracheostomy is also incidental to many other procedures, such as large glossectomies, Eisenberg says. You must trach the patient when youre removing the whole tongue, otherwise the patient cant breathe.

If the tracheostomy is performed for a reason other than that prompting the primary procedure, however, it is separately billed, as long as modifier -59 (distinct procedural service) is appended to the appropriate trach code.

For example, the otolaryngologist may see a patient with malignancy of larynx whose airway is somewhat compromised. An elective tracheostomy (31600) may be performed at the time of laryngoscopy because of concern about potential airway obstruction secondary to the edema related to the biopsy. In this case, the tracheostomy is performed to allow the patient to breathe, whereas a direct laryngoscopy with biopsy (31535) is performed to diagnose the malignancy in the patients larynx. Therefore, 31535 and 31600 may be reported separately. Modifier -59 should be appended to 31600.

Eisenberg also notes that it may be appropriate to append -59 to emergent trachs, such as 31603, because some carriers may assume these codes are included in the laryngoscopy.

Note: Although the national Correct Coding Initiative (CCI) lists several edits for codes 31600, 31603 and 31605, these procedures (especially 31600, because it is a separate procedure) may be bundled to other codes not listed in the CCI, on the grounds that they are included in the other procedure.

Trach Change Code Versus E/M

Trach tubes often require changing, particularly when a long-term tracheotomy is performed. CPT lists a single code 31502 for trach changes, and it should be used only before the fistula tract has been established.

There is no precise time after which one can safely say a fistula tract has definitely been established, Eisenberg says. He notes, however, that the tract is usually fully established within a week of the tracheostomy. Therefore, according to Eisenberg, any trach tube changed within a week of the original tracheostomy may be billed using 31502.

When you first place the trach, the fistula tract is not fully developed. Changing the tube during this period is more complicated than changing it after the tract is fully established, which is why CPT includes a separate code for this service, Cobuzzi says.

There is no code for trach tube changes performed after the fistula tract is established, Cobuzzi says. Changing the trach tube is considered part of the evaluation and management of the patient during a visit. The trach tube change is therefore included in the appropriate E/M service code used to report the patient encounter.

Cobuzzi notes that if the otolaryngologist accurately documents the entire E/M service and indicates the medical necessity for changing the trach, in some instances this 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.

Billing for an Assistant

According to the HCFA fee schedule, tracheostomy codes 31600, 31603, 31605 and 31610 do not allow for payment of assistant surgeons. The planned tracheostomy of a child under the age of two (31601) does permit an assistant surgeon, however.

In addition, Eisenberg notes, many carriers will reimburse for an assistant surgeon if a good reason for having the second surgeon is well documented. For example, he says, A second surgeon may be required if the patient is obese. In such cases, you may be able to bill for the assist. If the claim is denied, it can be appealed and may be paid as long as there is good documentation to support the appeal, Cobuzzi adds.

Related Procedures

Subsequent to a tracheostomy, the otolaryngologist may need to perform other procedures. For example, the stoma (opening) of patients with long-term tracheostomies may require simple or complex revision because the patient has had a laryngectomy and the stoma is stenosed. In complex cases, flap rotation must also be performed.

Depending on the complexity of the revision, one of the following two codes should be used:

31613 tracheostoma revision; simple, without flap rotation; 12.12 RVUs

31614 ... complex, with flap rotation; 18.28 RVUs.

Other patients may not require the tracheostomy after their breathing problem has been resolved. In such cases, the otolaryngologist closes the hole and removes the fistula that supported the tracheostomy. If the closure is complicated, plastic repair may be necessary.

CPT includes the following codes for the closure of tracheostomy and fistula:

31820 surgical closure tracheostomy or fistula; without plastic repair; 11.55 RVUs

31825 ... with plastic repair; 16.83 RVUs.