Pediatric Coding Alert

Question: Our pediatrician recently changed a trach tube in our office. How should we bill for this?

South Carolina Subscriber

Answer: CPT^® describes a specific procedure for removing a tracheotomy tube: 31502 (Tracheotomy tube change prior to establishment of fistula tract). However, the descriptor is very clear that this procedure is only performed prior to the establishment of the fistula tract. While there are no specific CPT^® guidelines that define when this occurs, the tract usually becomes established between a week to 10 days after the patient has had a tracheostomy. Before that time, changing the tube is difficult and is usually performed by an otolaryngologist.

As it is most likely that your pediatrician performed the removal after the patient’s fistula tract was established, you will most likely report the procedure as part of an evaluation and management (E/M) service using 99201 through 99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). But be sure to check with your provider before billing for the service to make sure you have full documentation concerning the date of the tracheostomy and the status of the tract at the time of the encounter.