© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 31601 refers to a planned tracheostomy performed on patients younger than two years of age. A tracheostomy is a surgical procedure that involves creating an opening in the trachea, or windpipe, to facilitate breathing. This procedure is typically indicated when a patient requires long-term ventilation support or has an obstruction in the upper airway that prevents normal breathing. During the procedure, the patient is positioned with their neck extended to provide optimal access to the trachea. The physician identifies and marks anatomical landmarks to ensure precision during the incision. A local anesthetic is administered along the incision line to minimize discomfort. The surgical steps involve incising the skin, removing subcutaneous fat, and carefully dissecting through the platysma muscle to reach the midline raphe between the strap muscles. The strap muscles are then separated and retracted to expose the pretracheal fascia and thyroid isthmus, which may be retracted or divided as necessary. The anterior face of the trachea is prepared, and an incision is made in a specific configuration to allow for the insertion of a tracheostomy tube. This procedure is critical for patients who need assistance with breathing, and it is performed with careful attention to anatomical structures to ensure safety and effectiveness.
© Copyright 2025 Coding Ahead. All rights reserved.
The planned tracheostomy procedure, as described by CPT® Code 31601, is indicated for patients younger than two years who may require assistance with breathing due to various medical conditions. The following are specific indications for performing this procedure:
The procedure for a planned tracheostomy involves several critical steps to ensure the safety and effectiveness of the intervention. Each step is performed with precision and care:
After the planned tracheostomy procedure, the patient will require careful monitoring and post-operative care. This includes ensuring the tracheostomy tube remains patent and secure, as well as monitoring for any signs of complications such as bleeding, infection, or tube displacement. The healthcare team will provide instructions on tracheostomy care, including cleaning and maintenance of the tube, and will assess the patient's respiratory status regularly. The patient may also require additional support, such as humidified oxygen, to aid in recovery and ensure adequate ventilation.
| Short Descr | PLANNED TRACHEOSTOMY<2 YRS | Medium Descr | TRACHEOSTOMY PLANNED UNDER 2 YEARS SPX | Long Descr | Tracheostomy, planned (separate procedure); younger than 2 years | 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) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | 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 | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 34 - Tracheostomy, temporary and permanent |
| 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). | 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. |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2025-01-01 | Changed | Short Description changed. |
| 2010-01-01 | Changed | Code description changed. |
| 2007-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |