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posterior tracheal tear

Elaine Posted Tue 11th of September, 2012 21:27:15 PM

How would you code:

A vertical incision was made in the lower anterior neck. Blunt and sharp dissection was used to isolate the trachea. A horizontal incision was made in the trachea and the patient was intubated through the trachea. The first pass of the end of the endotracheal tube did appear to go through the posterior tracheal wall defect. This was repositioned. The posterior tracheal tear was repaired with interrupted 4-0 Vicryl suture. Some Prolene stay stutures were placed in the area of the tracheotomy. The upper part of the trachea stoma was widened and sewed to the soft tissue and skin for easy reintubation. The endotracheal tube was sutured into place with 0 silk.

SuperCoder Answered Thu 13th of September, 2012 13:07:08 PM

Hi Elaine,

We can see that defect is present prior to intubation.I believe 31805 describes the procedure along with 31500. There is no CCI edit also between them.

Thanks
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