© Copyright 2025 American Medical Association. All rights reserved.
An intrathoracic tracheoplasty, designated by CPT® Code 31760, is a surgical procedure aimed at repairing defects located in the distal third of the trachea. This operation is critical for restoring the integrity and function of the trachea, which is essential for normal respiratory function. The specific approach taken during the procedure—either anterior or posterior—depends on the location and nature of the defect being addressed. In the anterior approach, a median sternotomy is performed, allowing access to the trachea by incising the anterior pericardium and retracting surrounding blood vessels to create a clear surgical field. Conversely, the posterior approach involves a right posterolateral thoracotomy, which entails dissecting the posterior mediastinal pleura and mobilizing the esophagus to gain access to the trachea. Throughout the procedure, careful attention is paid to protect critical structures such as the vagus and laryngeal nerves. Once the trachea is adequately exposed, the surgeon identifies the defect, which may involve incising the trachea if the defect is within the tracheal lumen. The repair may involve excising tracheal tissue and closing the defect with a patch or graft, potentially reinforced with a muscle flap or other tissue. The procedure concludes with the closure of the surgical incisions, ensuring that the patient can begin the recovery process.
© Copyright 2025 Coding Ahead. All rights reserved.
The intrathoracic tracheoplasty procedure is indicated for patients presenting with specific defects in the distal third of the trachea. These defects may arise from various conditions, including congenital malformations, traumatic injuries, or pathological processes that compromise the structural integrity of the trachea. The procedure aims to restore normal airflow and prevent complications associated with tracheal obstruction or dysfunction.
The procedure for intrathoracic tracheoplasty involves several critical steps, which are detailed below:
Post-procedure care following an intrathoracic tracheoplasty involves monitoring the patient for any signs of complications, such as infection or respiratory distress. Patients may require supportive care, including oxygen therapy, to ensure adequate respiratory function during the recovery phase. Follow-up evaluations are essential to assess the integrity of the tracheal repair and to monitor for any potential complications that may arise as the patient heals. The healthcare team will provide specific instructions regarding activity restrictions and signs of complications that should prompt immediate medical attention.
| Short Descr | TRACHEOPLASTY INTRATHORACIC | Medium Descr | TRACHEOPLASTY INTRATHORACIC | Long Descr | Tracheoplasty; intrathoracic | Status Code | Active Code | Global Days | 090 - Major Surgery | 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 | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 42 - Other OR therapeutic procedures on respiratory system |
This is a primary code that can be used with these additional add-on codes.
| 32674 | Add-on Code MPFS Status: Active Code APC C Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy (List separately in addition to code for primary procedure) | 38746 | Addon Code MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Thoracic lymphadenectomy by thoracotomy, mediastinal and regional lymphadenectomy (List separately in addition to code for primary procedure) |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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