Tracheostomy Coding: A Complete Guide for Accurate Medical Documentation

Indications / Associated Pathologies:

1. Congenital Anomaly
2. Neck Trauma
3. Respiratory Failure
4. Subcutaneous Emphysema
5. Upper Airway Edema, Foreign Body, or Obstruction

Description:

• Tracheostomy involves creating a stoma (surgical opening) in the neck to bypass the cervical trachea and/or oropharynx, allowing air to pass directly to the distal trachea for respiration.
• It may be performed on patients requiring long-term mechanical ventilation, those with trauma or neurological damage, or in cases of infection or malignancy.

Procedure Approaches:

1. Open Approach:
   • A horizontal neck incision is made, and muscles are dissected to expose the trachea.
   • The thyroid isthmus is cut if necessary. The trachea is then incised, and an airway is inserted.
   • Bleeding is controlled, and the stoma is created by suturing the skin to tissue layers.
   • This can be a planned or emergency procedure.
2. Percutaneous Approach:
   • A needle is inserted through the skin of the neck and into the trachea.
   • A cannula is threaded over the needle and secured with sutures.
   • Percutaneous Transtracheal Jet Ventilation (PTJV): A catheter is inserted through the cricothyroid membrane and connected to a high-pressure oxygen supply.
3. Percutaneous Dilatational Tracheostomy (PDT):
   • Typically performed at the bedside, PDT involves making an incision over the tracheal cartilage and inserting a needle and guidewire into the trachea.
   • A dilator enlarges the opening, and a tracheostomy tube is inserted.
   • Bronchoscopy may be used to visualize and confirm correct placement.
4. Percutaneous Endoscopic Approach:
   • A tracheostomy tube is inserted with endoscopic visualization of the operative site via an endoscope inserted percutaneously through the skin into the trachea.

• Regardless of the approach, the procedure is coded with the Tracheostomy Device and the qualifier Cutaneous, indicating that the root operation Bypass is performed from the trachea to the skin.

Focus Points for Medical Coders:

1. Tracheostomy vs. Tracheotomy:
   • Tracheostomy is a permanent or semi-permanent airway, while Tracheotomy refers to a temporary incision.
   • For tracheostomy, code from root operation table 0B1 (Bypass).
   • For tracheotomy, code from root operation table 0B9 (Drainage).
2. Code for Tube Replacement:
   • Do not report a new tracheostomy insertion if only the tracheostomy tube is being replaced or changed. Instead, report 0B21XFZ (Change Tracheostomy Device in Trachea, External Approach).
3. Endoscopic Guidance:
   • If a laryngoscope or bronchoscope is used to confirm the placement of a percutaneous tracheostomy, do not code the endoscopic inspection separately.
   • As per ICD-10-PCS Guideline B3.11a, “inspection of a body part performed to achieve the objective of a procedure is not coded separately.”

Body System:

• Respiratory System

Root Operation Tables:

1. 0B1: Bypass of Respiratory System (Altering the route of passage of contents of a tubular body part)

Body Parts:

• Trachea

Approaches:

1. Open
2. Percutaneous
3. Percutaneous Endoscopic

Device:

• Tracheostomy Device

Qualifier:

• Cutaneous

Common Associated Procedures:

1. Endotracheal Intubation
2. Mechanical Ventilation

Reimbursement:

• MS-DRG 003: ECMO or Tracheostomy with MV >96 hours or PDX (except face, mouth, and neck) with Major O.R. procedure
• MS-DRG 004: Tracheostomy with MV >96 hours or PDS (except face, mouth, and neck) without Major O.R. procedure
• MS-DRG 011-013: Tracheostomy for Face, Mouth, and Neck Diagnoses with MCC; with CC; without CC or MCC

Conclusion:

Medical coders must carefully differentiate between tracheostomy and tracheotomy, understand the procedure’s approach, and accurately apply coding guidelines based on the surgical approach and any associated procedures. Additionally, special attention should be given to documentation to avoid coding errors when dealing with tracheostomy tube changes or endoscopic guidance.