Use 31805 for an Intrathoracic Tracheal Wound Repair
Question: A patient was transported to the emergency department (ED) following a severe car crash. The patient experienced a neck injury with air leakage. The physician performed an imaging examination and confirmed the patient suffered a laceration to the trachea. A surgeon approached the wound through the thoracic cavity and repaired the injury. I’m new to surgical coding and I’m unsure of what code to select. Can you help? Vermont Subscriber Answer: Assign 31805 (Suture of tracheal wound or injury; intrathoracic) to report the surgical repair of the tracheal wound via an intrathoracic approach. Now, let’s break down how to arrive at that code. Open your CPT® code book to the Index. Under “R,” look for Repair. You’ll then follow the indentations to Trachea, Wound, and finally Intrathoracic, where you’ll discover 31805. You’ll then open the Surgery code section and verify the code under the Respiratory System subsection. Important: It’s critical that you pay attention to the surgeon’s documented approach, as 31800 (… cervical) sits just above 31805. The difference is that the surgeon would approach the tracheal wound from the back of the neck, also known as an anterior approach, with 31800. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
