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Please advise on coding

louise Posted Fri 12th of July, 2019 12:05:07 PM
31630 31899 31600 Direct laryngoscopy with magnification Tracheobronchoscopy with dilation with excision of granulation tissue Placement of new trach tube The stomal granulation tissue was then addressed transcervically since suspension laryngoscopy was not possible. suprastomal granulation tissue was excised with a microdebrider. The stoma was then progressively dilated up to a size 36 urethral dilator. Flexible bronchoscopy was then performed via the trach tube to suction blood/secretions--findings reported above
SuperCoder Answered Mon 15th of July, 2019 09:00:22 AM


As per the provided limited documentation, the appropriate CPT codes would be 31600 and 31899. Per operative report, physician performed placement of new tracheal tube for which CPT 31600 seems appropriate, for excision of granulation tissue CPT 31899 would be correct as there is no specific CPT code for the performed procedure.

Provided CPT 31630 would not be the correct code to use since the doctor introduced the bronchoscope through the tracheostomy tube and not through the nares or mouth.


First Solution:

One solution is to report 31630 with modifier 52 to represent a reduced service. This would allow payment for exactly what took place. Submit the claim with the same charge as 31630. You should never independently reduce the fee. Let the payer determine what they are going to pay based on what you report. The 52 modifier, of course, will trigger documentation review prior to payment.


Second Solution:

Since there is technically no correct code for this procedure, CPT code 31899 (Unlisted procedure, trachea, bronchi) is also a good option. Reporting 31899 is always acceptable when there is no procedure code that represents the actual service performed.

To describe flexible bronchoscopy and excision of granulation tissue, CPT code 31899 would be appropriate. So, the final codes would be 31600 and 31899.

Remember, the payer will request documentation before providing payment to identify what has been done. Make sure the doctor inserts a procedure description on the claim form as well as a fee for any unlisted procedures.


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