Otolaryngology Coding Alert

Question: Our otolaryngologist changes a patient's trach every four to six months. Due to the changes' frequency, cuff failure, and tracheostomy stoma tube stenosis, the physician performs the procedure at the hospital under general anesthesia. The change is difficult and somewhat risky, usually producing some bleeding from surrounding granulation tissue. How should I code the procedure?

Michigan Subscriber

Answer: CPT doesn't describe postfistula tracheostomy changes. Therefore, you should consider the change part of your physician's E/M service. Because the otolaryngologist replaces the tube in the operating room (OR) under anesthesia with no other procedure, use 92502 (Otolaryngologic examination under general anesthesia).

If your otolaryngologist clearly documents the case's increased difficulty and risk, you may append modifier -22 (Unusual procedural services) to 92502 to designate the additional work. Submit the operative report notes indicating the added risk associated with proximal bleeding.