Pulmonology Coding Alert

Take a second look at place of service before submitting 31899 and A4629.

Have you just encountered a tracheostomy tube change and are feeling lost while coding? Not to worry. Check out these five golden rules, and your claim is on its way to successful reimbursement.

What happens: The physician creates a neck incision and dissects the muscles to expose the tough cartilage rings that make up the outer wall of the trachea. If needed, the surgeon cuts the thyroid isthmus. He then creates an opening into the trachea and inserts a tracheostomy tube. He sutures the skin to the tissue layers to create a stoma, the opening in the neck. Quite frequently, patients have to approach their pulmonologists for regular tracheostomy tube changes, especially after the opening has formed a defined tract (usually, around 10 days). However, sometimes pulmonologists are required to intervene and change the trach tube even before the fistula tract has stabilized.

Rule 1: Think Before Coding 31502 

In absence of a specific code for a tracheostomy tube change, you might think the most obvious coding option is 31502 (Tracheotomy tube change prior to establishment of fistula tract). But you may regret that choice. A routine tracheostomy tube change such as this procedure (31502) usually occurs afew days within placement of the original tube.

Verify your dates: Submission of this code declares that your pulmonologist has changed a tracheotomy tube before the healing of fistula tract. The healing usually occurs 7-10 days after the tracheostomy and if the pulmonologist performs the trach tube change shortly after the tracheostomy surgery, it is clear that the tract has not yet become established.

Caution: The fistula establishment period can’t be nailed down definitively, as it varies from one patient to another. Therefore, CPT® has left it to the pulmonologist to report when the fistula has healed. You won’t find any restrictive guidelines on the exact period, but it’s imperative that the physicians document accurately when the patient’s tracheostomy tract has matured.

Rule 2: Provide Sufficient Documentation for 31899

Another option is to report 31899 (Unlisted procedure, trachea, bronchi). You can use this code in situations such as when your thoracic surgeon has performed a postfistula tracheostomy tube change in the OR on a patient under general anesthesia. No specific code exists for this procedure, so you can report 31899.

Heads up: Before your submissions, make sure you have the procedure description in laymen’s terms. If the payer asks for supporting documentation, you can include a cover letter. In the above-discussed scenario of the thoracic surgeon performing a tracheostomy, make sure your physician documented medical necessity to support performing the procedure. 

Equate the procedure to 31502 by providing detailed notes on the surgical work involved, the details of employed technology and technique and the time involved in performing it. You will also have to include the procedure description and fee on the claim since 31899 has no corresponding title or fee. “Despite attempts to secure reimbursement for a tube change in the OR when the patient is having another surgery, Medicare and some other payers will not reimburse for this.They see this as good patient care, but also as part of the surgical global package payment.This is true even when the surgery is performed by a specialist other than the one performing the trach change,” says Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania. 

Rule 3: Be Thorough With the Global Periods

Among the tracheostomy codes, 31610 (Tracheostomy, fenestration procedure with skin flaps) is a stand out in the sense that 31610 has a global period of 90 days. Most of them don’t have a global period. Consequently, you can’t bill for any related services, including trach tube changes, within the specified global period of 31610, except a return trip to the OR for some other complication.

Example: A patient experiences breathing difficulties due to amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease). The thoracic surgeon decides in favor of a tracheostomy using skin flaps to create a more permanent stoma. This is a typical example where you report 31610.

Rule 4: Make Use of an E/M Code Whenever Possible

You may feel out of depth while choosing the correct combination of specific codes for different trach tube changes, but in most cases, you can apply an E/M code. This is especially true in a nursing facility, office, or bedside setting after the tracheostomy tract has healed. Usually, payers perceive a simple tracheostomy tube change as a part of the E/M, and therefore, do not accept a separately reportable code.

Example: In a nursing home setting where you find yourself needing to code a bedside trach change on a regular basis, you may report the procedure as inclusive with the subsequent nursing facility care E/M codes (99307-99310) which may contribute tothe complexity of the E/M.

Rule 5: Be Sure to Include a Supply Code

The trach tube usually deteriorates over time after undergoing manipulations such as suctioning, inner canula cleaning or changing, etc. The physicians usually follow a tube change cycle of 3 to 6 months varying according to individual patients. 

You can safely code A4629 (Tracheostomy care kit for established tracheostomy) in such cases, depending obviously on the place of the change, as well as on your payer’s guidelines. You can use A4629 only whenreport in the office setting, and only if your practice incurred the cost of the kit.

Note: More and more nonsurgeons, such as pulmonologists, are performing percutaneous tracheostomy. Care of a tracheostomy patient by pulmonologists requires advanced training in tracheostomy and airway management, as well as skill in managing complications. The terms tracheostomy and tracheotomy are synonymous. ‘Tracheotomy’ refers to the operation while ‘tracheostomy’ is the actual opening in the neck through which patients breathe.