How To Use CPT Code 31610

CPT 31610 describes a procedure known as tracheostomy fenestration with skin flaps. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31610?

CPT 31610 is used to describe a specific procedure called tracheostomy fenestration with skin flaps. This procedure involves creating a permanent opening through the skin into the trachea using skin flaps. It is typically performed to assist patients with chronic conditions that cause breathing difficulties.

2. Official Description

The official description of CPT code 31610 is: ‘Tracheostomy, fenestration procedure with skin flaps.’

3. Procedure

1. The provider begins by preparing and anesthetizing the patient.
2. A horizontal neck incision is made through the muscles to expose the cartilage rings of the trachea.
3. An opening is created in the trachea for the insertion of a tracheostomy tube.
4. The provider sutures the skin flaps to the tissue layers, creating a permanent stoma or opening in the neck.

4. Qualifying circumstances

Tracheostomy fenestration with skin flaps is typically performed on patients with chronic conditions that cause breathing difficulties. This procedure is reserved for cases where other treatment options have been exhausted or are not suitable. It is important to note that this procedure should only be performed by a qualified healthcare professional with the necessary expertise and training.

5. When to use CPT code 31610

CPT code 31610 should be used when the provider performs a tracheostomy fenestration procedure with skin flaps. It is important to ensure that this specific procedure is documented accurately and that it aligns with the official description of CPT code 31610.

6. Documentation requirements

To support a claim for CPT code 31610, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for tracheostomy fenestration with skin flaps
• Details of the procedure performed, including the specific steps taken
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT code 31610, it is important to ensure that the procedure performed aligns with the official description. Additionally, it is crucial to follow any specific billing guidelines provided by the payer. It is also important to note that CPT code 31610 should not be reported with other codes unless there are specific circumstances that warrant it.

8. Historical information

CPT code 31610 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 with severe obstructive sleep apnea undergoes tracheostomy fenestration with skin flaps to improve their breathing.
2. A patient with a spinal cord injury requires tracheostomy fenestration with skin flaps to assist with long-term ventilation.
3. A patient with a history of head and neck cancer undergoes tracheostomy fenestration with skin flaps as part of their treatment plan.
4. A patient with a congenital airway abnormality undergoes tracheostomy fenestration with skin flaps to improve their respiratory function.
5. A patient with a severe respiratory infection requires tracheostomy fenestration with skin flaps to assist with breathing and facilitate the removal of secretions.