Our physicians have instances where they have seen patients in the hospital (in the ER and/or ICU) and do a trach tube change on an established trach. The only code I see for a trach change is 31502 which I know is for a trach change with a few days of placement of the original tube. I have inserted a procedure note that was performed, is there an appropriate code for what was performed?
PROCEDURE:
After discussion with anesthesia and procurement of supplies from OR, discussed risks and benefits with patient. He agreed that he would like to have a more secure airway. Lidocaine and afrin mixture was instilled into the trachea to repress cough partly. Flexible laryngoscope was advanced into the airway. The middle part of the trachea was significantly compressed but no mucosal lesions were appreciated and the normal caliber trachea resumed just above the carina which was clear. No purulent mucous or plugging was appreciated. The desired length was marked on the laryngoscope and measured to be 9.5 cm from skin to 1 cm above trachea. A 6.5 cuffless ET tube was trimmed to 15 cm, then split in half until the length was 9.5 cm. This was advanced gently into the airway without significant resistance. It was then withdrawn and the split "wings" of the upper portion of the ET tube were sutured to a Dale trach collar with 0 Silk sutures. the ET tube was then reintroduced and the collar secured around his neck. the patient had some coughing as expected but tolerated the procedure very well.
PROCEDURE:
After discussion with anesthesia and procurement of supplies from OR, discussed risks and benefits with patient. He agreed that he would like to have a more secure airway. Lidocaine and afrin mixture was instilled into the trachea to repress cough partly. Flexible laryngoscope was advanced into the airway. The middle part of the trachea was significantly compressed but no mucosal lesions were appreciated and the normal caliber trachea resumed just above the carina which was clear. No purulent mucous or plugging was appreciated. The desired length was marked on the laryngoscope and measured to be 9.5 cm from skin to 1 cm above trachea. A 6.5 cuffless ET tube was trimmed to 15 cm, then split in half until the length was 9.5 cm. This was advanced gently into the airway without significant resistance. It was then withdrawn and the split "wings" of the upper portion of the ET tube were sutured to a Dale trach collar with 0 Silk sutures. the ET tube was then reintroduced and the collar secured around his neck. the patient had some coughing as expected but tolerated the procedure very well.
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