How To Use CPT Code 31601

CPT 31601 describes the surgical procedure known as tracheostomy, specifically for patients younger than two years old. 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 31601?

CPT 31601 represents a planned tracheostomy procedure performed by a healthcare provider on patients who are younger than two years old. This surgical procedure involves creating an opening in the trachea, or windpipe, to assist with breathing and the removal of secretions from the airway.

2. Official Description

The official description of CPT code 31601 is: ‘Tracheostomy, planned (separate procedure); younger than 2 years.’

3. Procedure

1. During a planned tracheostomy, the patient is appropriately prepped and anesthetized.
2. The healthcare provider makes a neck incision and divides the overlying muscles to expose 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. This procedure is performed to assist patients with obstructed airways, aid in breathing, and facilitate the cleaning and removal of secretions from the airway using a suction tube.

4. Qualifying circumstances

CPT 31601 is applicable to patients who are younger than two years old and require a planned tracheostomy procedure. This procedure is typically performed on patients who have obstructed airways, need long-term ventilatory support, or require assistance in breathing and airway management.

5. When to use CPT code 31601

CPT code 31601 should be used when a healthcare provider performs a planned tracheostomy procedure on a patient who is younger than two years old. It is important to note that this code should not be reported in addition to another code if the tracheostomy is considered an integral part of the total surgery or service.

6. Documentation requirements

To support a claim for CPT 31601, the healthcare provider must document the following information:

• Patient’s age and the need for a planned tracheostomy
• Details of the procedure, including the specific steps taken
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 31601, ensure that the procedure is a planned tracheostomy performed on a patient younger than two years old. It is important to determine if the tracheostomy is a separate procedure and not report it in addition to other codes that already include the tracheostomy. For emergency tracheostomies, different codes should be used. It is recommended to review the specific billing guidelines and tips provided by the payer to ensure accurate reporting.

8. Historical information

CPT 31601 was added to the Current Procedural Terminology system on January 1, 1990. There have been historical changes to the code, including code updates on January 1, 2007, and January 1, 2010.

9. Examples

1. A healthcare provider performs a planned tracheostomy on a 1-year-old patient with a severe airway obstruction.
2. A surgeon performs a tracheostomy procedure on a 6-month-old infant who requires long-term ventilatory support.
3. A pediatric otolaryngologist performs a planned tracheostomy on a 2-year-old child with a congenital airway anomaly.
4. A neonatal intensive care unit team performs a tracheostomy on a premature newborn with respiratory distress syndrome.
5. A pediatric surgeon performs a planned tracheostomy on a 1-month-old infant with a complex congenital heart defect.
6. A healthcare provider performs a planned tracheostomy on a 1-year-old patient with a severe upper airway obstruction due to a tumor.
7. A pediatric otolaryngologist performs a tracheostomy on a 6-month-old infant with a bilateral vocal cord paralysis.
8. A surgeon performs a planned tracheostomy on a 9-month-old patient with a tracheal stenosis.
9. A neonatal intensive care unit team performs a tracheostomy on a premature newborn with a congenital diaphragmatic hernia.
10. A pediatric surgeon performs a planned tracheostomy on a 2-year-old child with a severe subglottic stenosis.