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Tracheostoma dilation?


Midlothian, VA
Best answers
I was wondering if anyone had any suggestions for the following situation?

The physician did an elective tracheostomy on the patient over a year ago. The patient has continued to have multiple issues and has been in and out of the hospital. Today the physician decided that the patients tube needed to be changed to a larger size. The procedure note states "She had a #4 tracheostomy in place. A Blue Rhino dilator was utilized to dilate the tracheal stoma up to a 38 French. A #6 percutaneous tracheotomy tube was then inserted through the tracheal stoma. A small amount of bleeding occurred that stopped shortly thereafter. The patient tolerated the procedure well and there were no complications..."

Looking at 31502; Tracheotomy tube change prior to establishment of fistula tract , this doesn't seem appropriate because this was not a recent trach.

31613; Tracheostoma revision; simple without flap rotation; I'm wondering if this applies, but it seems that there is a lot more work involved with this code. The stoma wasn't completely revised and there were no sutures involved.

Any suggestions on how to code this?