How To Use CPT Code 31600

CPT 31600 describes a surgical procedure known as tracheostomy, which involves creating an opening in the trachea to assist with breathing and airway management. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31600?

CPT 31600 represents a planned tracheostomy, a surgical procedure performed by a healthcare provider to create an opening in the trachea. This procedure is typically done to assist patients with breathing, manage their airway, and remove secretions using a suction tube. Tracheostomy is often performed in patients who have been intubated for an extended period or require long-term ventilatory support.

2. Official Description

The official description of CPT code 31600 is: ‘Tracheostomy, planned (separate procedure).’ This code specifically refers to a planned tracheostomy procedure, which is performed in patients with obstructed airways or those who require assistance in breathing and airway management.

3. Procedure

1. After appropriate patient preparation and anesthesia, the healthcare provider makes an incision in the neck and divides the overlying muscles.
2. The goal of the procedure is to expose the cartilage rings that make up the outer wall of the trachea.
3. If necessary, the provider may remove the thyroid isthmus, which is the band of tissue joining the lobes of the thyroid gland.
4. An opening is created in the trachea, and a tracheostomy tube is inserted to maintain the airway.
5. The provider sutures the skin to the adjacent tissues, creating an opening that connects the neck to the tracheostomy site.
6. The procedure allows for improved breathing, airway clearance, and the ability to manage secretions using a suction tube.

4. Qualifying circumstances

CPT 31600 is performed in patients who require a planned tracheostomy to address an obstructed airway or to assist with breathing and airway management. This procedure is typically done in patients who have been intubated for a long period or require long-term ventilatory support. It is important to note that emergency tracheostomies, performed in situations where the patient’s airway is severely compromised, have separate codes (31603 or 31605) and should not be reported with CPT 31600.

5. When to use CPT code 31600

CPT code 31600 should be used when a planned tracheostomy procedure is performed. It is appropriate for patients who require assistance with breathing, airway management, and secretion clearance. This code should not be used for emergency tracheostomies or when reporting codes for the total surgery or service that includes the tracheostomy procedure.

6. Documentation requirements

To support a claim for CPT 31600, the healthcare provider must document the following information:

• Reason for the planned tracheostomy procedure, such as an obstructed airway or the need for long-term ventilatory support
• Details of the procedure, including the specific steps performed
• Date of the procedure
• Any additional findings or complications encountered during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 31600, ensure that the procedure performed is a planned tracheostomy and not an emergency procedure. It is important to determine whether the tracheostomy is a separate procedure and not report it in addition to codes for the total surgery or service. Follow the appropriate coding guidelines and modifiers when reporting CPT 31600.

8. Historical information

CPT 31600 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient who has been intubated for a long period requires a planned tracheostomy to assist with breathing and airway management.
2. A patient with a history of obstructed airway needs a tracheostomy to improve breathing and airway clearance.
3. A patient with long-term ventilatory support requires a planned tracheostomy to facilitate airway management and secretion clearance.
4. A patient with a severe respiratory condition requires a planned tracheostomy to ensure adequate oxygenation and ventilation.
5. A patient with a progressive neuromuscular disorder needs a tracheostomy to support long-term respiratory care.
6. A patient with a traumatic injury to the airway requires a planned tracheostomy for airway stabilization and management.
7. A patient with a chronic lung disease requires a planned tracheostomy to improve breathing and reduce the risk of complications.
8. A patient with a congenital airway abnormality needs a tracheostomy to maintain a patent airway and ensure adequate oxygenation.
9. A patient with a head and neck tumor requires a planned tracheostomy to address airway obstruction and facilitate treatment.
10. A patient with a severe infection of the upper airway requires a planned tracheostomy for airway management and secretion clearance.