Wiki TRACH WITH DIVISION OF ISTHMUS

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sbuck328

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Hi everyone! Help appreciated. My provider is insisting on billing 60200 with 31600 as he feels division of the isthmus is not included in the trach procedure. He states it is more extensive as it requires more expertise and there is greater risk of bleeding. Codes are not bundled, however, all information I am finding states division of the isthmus is a part of the trach procedure. Does anyone have solid information on this that I can provide to him? He also states he does them percutaneously, not always surgically, which is still CPT 31600. UGH!
Much appreciation!!
 
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I don't see how a trach can be accomplished without dividing the isthmus, regardless of approach. And if there is such a high risk of hemorrhage, why is he doing the procedure "percutaneously"? The only percutaneous procedure I find is 31612 for transtracheal aspiration and/or injection. However, if the purpose of the procedure is to ultimately insert a tracheostomy tube for ventilation, this code isn't right either.
Can you provide at least the Pre/post op Dx and the portion of the note that describes the exact procedure?
 
DIAGNOSIS: (1) COVID pneumonia (2) Ventilator dependent respiratory failure
OPERATION: (1) Planned Tracheostomy (2) lsthmustectomy
DESCRIPTION OF PROCEDURE:
The patient was placed in the supine position with the neck extended. Laryngotracheal and
anterior neck landmarks were identified, including the thyroid notch, cricoid cartilage and
sternal notch. A horizontal incision midway between the cricoid cartilage and sternal notch was
delineated. Local anesthetic (1% lidocaine with epinephrine 1:1 00,000) was infiltrated
subcutaneously. The neck was prepped and draped in the usual sterile fashion.
Using a No. 15 scalpel, an incision was made through skin and subcutaneous tissue along the
marked path. The superficial cervical fascia and platysma muscle were identified and divided
sharply. The superficial layer of the deep cervical fascia was then identified and divided in a
vertical fashion along its midline raphe using monopolar electrocautery. The sternohyoid and
sternothyroid muscles were identified bilaterally. Dissection continued until the thyroid isthmus
was identified. The isthmus was then partially divided with bipolar electrocautery.
The pretracheal fascia was then encountered and separated from the underlying trachea using
a combination of blunt dissection and electrocautery. The cricoid cartilage and upper tracheal
rings were identified. A decision was made to enter the airway by creating a tracheal window
with removal of the second ring. The ETT cuff was deflated by the anesthesiologist. Using a No.
15 scalpel, the membranous space between rings 1 and 2 was scored; a Metz scissors were
used to complete the incision bilaterally and create a tracheal window. The ETT was gradually
withdrawn until the distal end was just above the tracheotomy. The tracheotomy was dilated
using a dilator instrument. The tracheostomy tube (a #6 Shiley cuffed tube) was inserted into
the trachea. Correct placement was confirmed by the effortless passage of a flexible suction
catheter, suctioning of tracheal secretions, and proper tidal volumes when the ventilator circuit
was connected. The tracheostomy tube was secured by suturing the neck plate at four points using
2-0 silksuture. It was further secured with a snugly-fitted soft Velcro collar. A long strip of petrolatum
gauze dressing was packed into the wound around the tracheostomy tube for hemostasis. The patient
was then turned over to the anesthesia and ICU teams for further care.

THANK YOU!
 
This looks like a routine tracheostomy to me, done by without any extra work to divide the isthmus. 31600 for an adult is the procedure as written in my opinion.
As I'm researching this, I noticed the Operation is described as "Isthmustectomy"- removal of isthmus, which is incorrect. It should read "isthmustotomy"- incision into isthmus. But this is beside the point.

For some reason some doctors don't see the risks their taking with being audited for up-charging and I'm not sure how to effectively communicate this without having a working relationship with that physician.
 
Absolutely agree with you. Thank you for your input! It is greatly appreciated. He "respectfully disagrees with me". I don't know what else to tell him. Respiratory diagnosis codes will not be supported for 60200 either. Oh well, I was hoping to find some sort of credible documentation to submit to him but I can't seem to find any.
 
I agree it won't be supported by a resp Dx code. And if every layer from skin to target (neck to trachea) was supposed to be coded, it wouldn't already be computed into the allowed fee for the CPT code.
The description of 60200 specifies "removal...." - what else is to understand since there was no tissue removed, just pushed aside.
 
I don't know, the description of the code does indicate transection of isthmus so I understand his view, but he's doing the procedure as part of the tracheostomy to gain access to the trach, not for a thyroid condition, I have no idea what to do at this point. I advised his billing staff that I will not be coding it that way, If he wants it billed that way, that's on him. I like having credentials after my name. If I am wrong, I would love for someone on here to let me know. That was the reason for my post. I'd rather be safe than sorry. Why is there no info out there on billing 31600 & 60200 together for a trach? Ugh...frustrated! Thanks for your help!!
 
Stick to your guns on this - you are right. There's no info on it because the action required to access the traches inherently includes the attention paid to all the anatomy from point A to point B.
If we had to code every layer encountered during a surgical procedure, well, that would be total chaos. Parting the isthmus is just how you access the trachea. Period.

Don't forget - Physicians write these codes, they know how these procedures are accomplished and how much work is involved.
 
FYI: Reply from AAPC Expert on this matter.

Thank you for the query!

Excision of Isthmus is considered a part of the major procedure (tracheostomy) and should not be billed

separately. The services of excision of isthmus would be included in tracheostomy.

CPT code 60200 should be billed as a standalone procedure for excision of cyst or adenoma of thyroid,

or transection of isthmus, when performed in the absence of tracheostomy.

Thanks!
 
sbuck328 said:
FYI: Reply from AAPC Expert on this matter.

Thank you for the query!

Excision of Isthmus is considered a part of the major procedure (tracheostomy) and should not be billed

separately. The services of excision of isthmus would be included in tracheostomy.

CPT code 60200 should be billed as a standalone procedure for excision of cyst or adenoma of thyroid,

or transection of isthmus, when performed in the absence of tracheostomy.

Thanks!
Click to expand...
Where did you get the information from the "AAPC Expert"? I have having the exact same problem with my provider and he doesn't agree with me either. I need proof that this cannot be billed together. Glad I am not alone.
 
Do you have any surgical nurses on staff at your office that could help you convince your doctor that this is the way all surgeries are coded!
Somewhere in my course of learning I remember a statement like: code to the deepest body part reached. It could have been in the Inpatient coding course
 
I think the providers that question the coding of their procedures are actually questioning the abilities of the coder to understand their work. If the coder can't explain the rationale for why they chose a particular code, why should the provider have any confidence in the coder. Just my opinion.
 
Also consider that a trach is a separate procedure. It is included in any other procedure performed in the same area. You cannot code a trach and another code.
 
andijo said:
Where did you get the information from the "AAPC Expert"? I have having the exact same problem with my provider and he doesn't agree with me either. I need proof that this cannot be billed together. Glad I am not alone.
Click to expand...
AAPC provides a service called AAPC Expert where you may submit questions, with redacted op-reports if needed, and an expert will reply with their findings. There is a fee and you have to submit payment for each question before they will review them. My company pays so I am not sure how much the charge is per question. I know It's not much, like $25 for members, something like that.
 
fwnewbie said:
Do you have any surgical nurses on staff at your office that could help you convince your doctor that this is the way all surgeries are coded!
Somewhere in my course of learning I remember a statement like: code to the deepest body part reached. It could have been in the Inpatient coding course
Click to expand...
Unfortunately, no
 
Since they didn't get the division of the isthmus, they are now trying to bill a cervical lipectomy with their trachs with no medical necessity as to why the lipectomy was performed. Op-report DX indicates vent-dependent respiratory failure. Documentation indicates after neck incision, subcutaneous fat encountered and excised. They are trying anything to get more money for these trachs. They are driving me crazy!
 
Nowhere in that op note does it discuss any lipectomy. Can you confer with the facility coding department to compare their procedure coding? I don't know if that's commonly done but the facility procedure and the surgeon procedure should match, shouldn't it?
Or could you check with someone in your local chapter for ideas on squelching their way of thinking?
 
sbuck328 said:
Since they didn't get the division of the isthmus, they are now trying to bill a cervical lipectomy with their trachs with no medical necessity as to why the lipectomy was performed. Op-report DX indicates vent-dependent respiratory failure. Documentation indicates after neck incision, subcutaneous fat encountered and excised. They are trying anything to get more money for these trachs. They are driving me crazy!
Click to expand...
Were you ever successful at getting your point across that a trach includes dividing all the tissues between the skin and the trachea?? And if a little blob of fat needs to be removed for visualization, that's just part of the job?
 
I agree that this is routine trach, not a lipectomy. As you stated, Sue, there has to be medical necessity to do a procedure. The fat is incidental to the trach.
 
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