Pulmonology Coding Alert

Question: Does anyone know if we can charge for trach decannulation? If so, what is the CPT code? This was the only reason the physician was called in.

Hawaii Subscriber

Answer: This is a five-minute procedure which you should bill with inpatient subsequent hospital care 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.) or 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.).

The first step in determining whether you can increase your inpatient coding levels is to know what constitutes each service level. Then you should move on to review the documentation. Here are basic guidelines for the two subsequent hospital care levels:

• 99231 -- Patient is stable, recovering, or improving
• 99232 -- Patient is responding inadequately to therapy or has developed a minor complication

On the other hand, tracheostomy decannulation is the removal of the tracheostomy tube. The physician should consider this only if the original upper-airway obstruction is resolved, if airway secretions are controlled, and if mechanical ventilation is no longer needed.

If the physician performed a complex trach tube change, you should report 31502 (Tracheotomy tube change prior to establishment of fistula tract). Remember, this code is not for a routine change of a tracheotomy tube, but for a complicated tracheotomy tube change requiring reestablishment of a fistula tract which has not yet been permanently formed. Routine change of a trach tube should not be separately reported from E/M visit.