Pulmonology Coding Alert

Coding a tracheostomy tube change? Avoid these 5 pitfalls to create picture perfect claims that will get your pulmonologist paid -- the first time around.

Background: Patients find themselves needing regular trach tube changes, particularly after the opening has formed a defined tract (in about 10 days). But sometimes, pulmonologists have to change the trach tube even before the fistula tract is established.

Do you know what to do? Read on to find out.

If you're lacking a specific code defined for changing a tracheostomy tube, then you may think 31502 (Tracheotomy tube change prior to establishment of fistula tract) is the most viable option. The truth is you should not use this code for a routine tracheostomy tube change.

"This procedure (31502) is performed usually a few days within placement of the original tube," adds Charlyne Hill, CPC, of Sunrise Medical in Phoenix, Arizona.

Check your dates: Reporting 31502 means your pulmonologist changed a tracheotomy tube before the fistula tract has healed; the healing occurs 7-10 days after the pulmonologist performs the tracheostomy, says Karla M. Westerfield, COPM, business manager of the Southeast Wyoming Ear, Nose & Throat Clinic in Cheyenne.

"In the case of my surgeons, the trach tube change is done shortly after the tracheostomy surgery so it is clear that the tract has not become established," says Janet Kidneigh, CPC-A, of The Children's Hospital in Aurora, Colo.

Heads up: CPT has no guidelines saying when the fistula actually becomes established since it varies from patient to patient. Physicians have the last say on this matter, but imperative that they document when the tracheostomy tract is mature.

"The documentation should indicate that (maturity) for purposes other than billing.

Clinical observation at the time of tube change should include a statement about the status of the trach site," notes Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Pitfall 2: You Don't Supply Enough Documentation for 31899

Another option is that you can try submitting 31899 (Unlisted procedure, trachea, bronchi).

Example: Your thoracic surgeon performs a postfistula tracheostomy tube change in the OR, with the patient under general anesthesia. No specific code exists for this procedure, so you can report 31899.

Watch out: When submitting the claim, be sure to manually enter a procedure description and a fee. After prompted for documentation by the insurer, you should enclose a cover letter explaining the procedure. In our example of the thoracic surgeon performing a tracheostomy tube change under general anesthesia, make sure you document medical necessity to support performing the procedure. Better yet, benchmark the procedure to 31502 by describing how the surgical work is done, the technology and technique used, and the time involved in performing it.Consider appending modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to 31899 when the thoracic surgeon can't perform the trach change in the office, thus taking the patient to the OR [e.g. the patient has a significant complication from the tracheostomy and may need a revision of the tracheostomy site] if the procedure falls within the postoperative period of the initial procedure.

Most tracheostomy codes don't have global periods except 31610 (Tracheostomy, fenestration procedure with skin flaps), which has 90 days. The catch is you cannot bill for related services (that do not require a return trip to the OR) -- including trach tube changes -- within the specified global period of 31610.

Example: A patient's amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease) causes him to experience difficulty in breathing. As a result, the thoracic surgeon decides to perform a tracheostomy using skin flaps to create a more permanent stoma, or opening. You would code this extensive procedure as 31610.

As much confusion as there is about which specific code goes with a trach tube change, more often than not an E/M code still applies, especially in a nursing facility, an office, or a bedside after the tracheostomy tract heals. Most payers would likely view a simple tracheostomy tube change as an inclusive service within the E/M, thus, not separately reportable.

Example: In a nursing home setting where you find yourself needing to code a bedside trach change on a regular basis, you may report the procedure as inclusive with the subsequent nursing facility care E/M codes (99307-99310) which increases the complexity of the E/M.

Pitfall 5: You Forgo Supply Code

The tracheostomy tube is usually changed every 3 to 6 months depending on how well the trach tube withstands the manipulation (suctioning, inner canula cleaning or changing, etc.) over time. As the frequency varies on a particular patient, make sure you check with your physician on how often the change should take place. As long as the physician provides the tube change supplies, you are allowed to report it so you can recoup any expenses. The code A4629 (Tracheostomy care kit for established tracheostomy) applies. Nonetheless, this will depend on where the change takes place, as well as on your payer's guidelines. Keep in mind that A4629 is used strictly for reporting office services only.

Quick fact: More and more nonsurgeons, such as pulmonologists, perform percutaneous tracheostomy. Care of a tracheostomy patient by pulmonologists requires advanced training in tracheostomy and airway management, as well as skill in managing complications. The terms tracheostomy and tracheotomy are synonymous. 'Tracheotomy' refers to the operation while 'tracheostomy' is the actual opening in the neck through which patients breathe.