Pulmonology Coding Alert

Question: The CPT Assistant indicates that I should report 31502 for complicated tracheostomy tube changes before the patient established a fistula tract.
However, what should I report if one tracheostomy tube was leaking air and the other tracheostomy tube was not working properly and prevented the pulmonologist from ventilating the patient? As a result, the pulmonologist placed a third tracheostomy tube in an unstable airway and then inserted an extended tube into the tracheal stoma. 

I know that I should report 31502 when the pulmonologist notes that the patient's fistula tract is not established. But if the pulmonologist's report does not specify whether the patient's fistula tract is established or not, is there any way I can make an educated guess? 


Maryland Subscriber


Answer: Usually, establishing a mature tract after  a pulmonologist performs a tracheostomy takes about a week. 

If the pulmonologist changes a tracheostomy tube prior to the maturation of the patient's tract, you should report 31502 (Tracheotomy tube change prior to establishment of fistula tract). 

If the pulmonologist changes a tracheostomy tube after the patient establishes a fistula tract, you should incorporate the tube change into the E/M for the day. 
 
The multiple tracheostomy tube changes  described in your scenario are not specifically covered by CPT codes.
 
However, if these changes occurred when the pulmonologist administered critical care, you can consider the time the pulmonologist takes to treat this patient as critical care time. You should include however much additional critical-care time the pulmonologist spent treating that patient on that day.
 
If your pulmonologist did not administer critical care, you can use the time the pulmonologist spent to make the tracheostomy tube changes to increase the complexity of the hospital visit for that day.

If the pulmonologist performed the tracheostomy tube changes in the office, you should fold the tube changes into the E/M for that visit.