Basics of Tracheostomy CPT code

A tracheostomy is a medical procedure that involves creating an opening in the neck in order to place a tube into a person’s windpipe.

In medical coding, their are lot of minimal invasive procedures which are performed percutaneously. For example about chest tube placement, arthrocentesis, a, myelogram, breast biopsy, thoracentesis, paracentesis, abscess drainage etc . Tracheostomy is also performed percutaneously.  

Also, we will check the different tracheostomy CPT code used for Planned and Emergency exams.

Diagnosis required  with Percutaneous Tracheostomy CPT code

• anaphylaxis
• birth defects of the airway
• burns of the airway from inhalation of corrosive material
• cancer in the neck
• chronic lung disease
• coma
• diaphragm dysfunction
• facial burns or surgery
• infection
• injury to the larynx or laryngectomy
• injury to the chest wall
• need for prolonged respiratory or ventilator support
• obstruction of the airway by a foreign body
• obstructive sleep apnea
• paralysis of the muscles used in swallowing
• severe neck or mouth injuries
• tumors
• vocal cord paralysis

Read also: Best coding tips for Fine needle aspiration CPT codes

Percutaneous & Emergency tracheostomy cpt code description

The physician performs a planned tracheostomy on a patient two years or older (CPT code 31600) or younger than two years (CPT code 31601). 

In this exam, the physician creates a tracheostomy. The physician makes a horizontal neck incision and dissects the muscles to expose the trachea. The thyroid isthmus is cut if necessary. The trachea is incised and an airway is inserted. After bleeding is controlled, a stoma is created by suturing the skin to the tissue layers. In CPT code 31600, the tracheostomy is a planned procedure. In CPT code 31601, it is a planned procedure performed on patients younger than 2 years of age.

In CPT code 31603, it is performed under emergency conditions by puncturing the trachea and inserting a cannula. In CPT code 31605, it is performed under emergency conditions by puncturing the cricothyroid membrane located just above the cricoid and inserting a cannula. This is not a true tracheostomy and is usually converted to a tracheostomy once the situation is no longer emergent. In 31610, skin flaps are used to create a more permanent stoma.

CPT code 31603 & 31605 are used coding Emergency tracheostomy. In 31605, an emergency cricothyroid membrane tracheostomy is peformed. The cricoid cartilage is palpated and an incision made horizontally above its superior border. The cricothyroid membrane is exposed and punctured at the midline with the blade directed inferiorly to prevent damage to the true vocal cords. The incision is widened and a cannula inserted for ventilation.

Providers perform emergency tracheostomies when a patient’s upper airway is obstructed,  where the patient cannot be intubated.

31603 Tracheostomy, emergency procedure; transtracheal for a transtracheal approach

31605 Tracheostomy, emergency procedure; cricothyroid membrane

In 31610, a tracheostomy is performed using a fenestration procedure with skin flaps. 

ICD-10-CM Codes that support Tracheostomy cpt code