Need help choosing the right code?
Ask CasePilot about procedures, modifiers, bundling, and coding guidance.
Try CasePilot© Copyright 2026 American Medical Association. All rights reserved.
A percutaneous tracheal puncture, as described by CPT® Code 31612, is a medical procedure that involves creating a small opening in the trachea to facilitate transtracheal aspiration and/or injection. This procedure is typically indicated for patients who require access to the trachea for therapeutic purposes, such as the aspiration of fluid or the administration of medications directly into the trachea. The procedure begins with a small stab incision made over the trachea, specifically at the level of the cricoid cartilage, which is located in the neck. Following the incision, a needle or catheter is carefully advanced through the surrounding thyroid tissue and into the trachea itself. Once access to the trachea is achieved, the physician can aspirate any fluid present or inject medications or other pharmacological substances as needed. After the procedure is completed, the needle or catheter is withdrawn, and the stab incision is typically closed using sutures or an adhesive patch to promote healing and prevent complications. This procedure is essential in various clinical scenarios where direct access to the airway is necessary for effective treatment.
© Copyright 2026 Coding Ahead. All rights reserved.
The percutaneous tracheal puncture procedure (CPT® Code 31612) is indicated for specific clinical situations where direct access to the trachea is required. The following conditions may warrant this procedure:
The procedure for a percutaneous tracheal puncture involves several critical steps to ensure safety and effectiveness. The following outlines the procedural steps:
Post-procedure care following a percutaneous tracheal puncture is essential to ensure proper healing and monitor for any potential complications. Patients are typically observed for any signs of respiratory distress, bleeding, or infection at the incision site. Instructions may include keeping the area clean and dry, monitoring for any unusual symptoms, and following up with the healthcare provider as directed. Recovery time may vary depending on the individual patient's condition and the complexity of the procedure performed.
| Short Descr | PERQ TRCHL PNXR TTRACH ASPIR | Medium Descr | TRACHEAL PNXR PERQ W/TRANSTRACHEAL ASPIR&/NJX | Long Descr | Tracheal puncture, percutaneous with transtracheal aspiration and/or injection | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 42 - Other OR therapeutic procedures on respiratory system |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | GC | This service has been performed in part by a resident under the direction of a teaching physician | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.