Get Answers to Trach Coding FAQs
Know what separates tracheotomies and tracheostomies. Tracheotomies and tracheostomies are two procedures that often get confused with one another due to how similar their names are. At first glance they are remarkably similar, aside from the “s” in the middle of one of the names. These two related procedures involve the trachea, but their purposes and durations are what separates them. Revenue Cycle Insider dives into the distinction between the two procedures, and then the coding specifics by answering frequently asked questions (FAQs). What is the difference between a tracheotomy and a tracheostomy? A tracheotomy is a surgical procedure where the physician makes an incision in the trachea to provide access to the airway. This procedure temporarily relieves airway obstruction or provides access for breathing. Tracheotomy refers to the incision itself. On the other hand, a tracheostomy is the creation of a stoma (opening) that connects the trachea to the outside of the body. This often involves placing a tube to maintain the opening. The procedure is permanent and is used for long-term ventilation, usually when the normal airway is compromised. Which codes do I assign for each procedure? There are two types of procedures — one is an emergency and the other is planned. What substantiates an emergency tracheotomy is it will typically be performed in life-threatening situations where the patient has an immediate airway obstruction or respiratory failure requiring urgent intervention. Urgent examples include acute airway obstruction and severe respiratory distress requiring immediate airway access. A planned tracheotomy, however, would be a scheduled procedure done for non-urgent reasons, often to provide long-term airway support. Examples include chronic respiratory failure requiring prolonged mechanical ventilation and elective tracheotomy in preparation for surgery. Like the tracheotomy, a tracheostomy should also constitute an emergency or planned procedure. An emergency tracheostomy is performed when there is an acute, life-threatening situation requiring immediate intervention to secure the airway. Conditions needing urgent attention are airway obstruction from trauma, acute respiratory failure when intubation can’t be done, and rapidly progressive infections causing airway compromise. The planned tracheostomy would be performed electively in controlled conditions for long-term airway or ventilatory management. Some examples are chronic respiratory failure requiring prolonged mechanical ventilation, neuromuscular diseases needing airway support, head and neck cancers, and surgical preparation for airway management. How do we show the medical necessity for a tracheotomy? To report a procedure code, you must show the medical necessity for the physician’s services. The documentation and ICD-10-CM codes show the reason the provider performed the procedure. In the case of 31500 (Intubation, endotracheal, emergency procedure), the diagnosis codes that need to accompany a tracheotomy depends on the underlying medical condition for the procedure. Common conditions that require a tracheotomy include: Are tracheostomy-related diagnosis codes the same for tracheotomies? You’ll report tracheostomy procedures with any of the following codes, depending on what the provider includes in the documentation: The diagnosis codes that accompany a tracheostomy are the same as the ones that accompany a tracheotomy. You’ll determine the diagnosis codes by the content of the medical records. Choose from the following ICD-10-CM codes to correctly report a tracheostomy: A clear understanding of the distinctions between tracheostomy and tracheotomy, along with their specific coding requirements, is essential for maintaining precise and comprehensive medical documentation. Although these procedures are closely related, they differ significantly in their purpose, duration, and clinical indications. Additionally, the circumstances under which these procedures are performed — whether in emergency situations or as planned interventions — further highlight their unique applications. By accurately distinguishing between these procedures and applying the correct coding guidelines, you can help ensure proper reimbursement. Crystal Nguyen, CPC, Certified Coding Specialist,
RHACE Division, Pinnacle Enterprise Risk Consulting Services
