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The procedure described by CPT® Code 31781 involves the excision of tracheal stenosis and subsequent anastomosis, specifically utilizing a cervicothoracic approach. Tracheal stenosis refers to the narrowing of the trachea, which can lead to significant respiratory difficulties. In this procedure, the stenotic segment of the trachea is surgically removed, and the remaining proximal and distal segments are then reconnected, or anastomosed, to restore normal airflow. This code is specifically used when the stenosis extends into the distal third of the trachea, necessitating a more invasive surgical approach compared to procedures that address stenosis located in the proximal or middle thirds of the trachea. The cervicothoracic approach allows for adequate exposure of the trachea, which is essential for the successful excision of the narrowed segment and the subsequent reconstruction of the airway. The procedure may also involve additional techniques, such as sliding tracheoplasty, to optimize the airway's diameter and functionality. Overall, CPT® Code 31781 captures a complex surgical intervention aimed at alleviating airway obstruction caused by tracheal stenosis.
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The procedure coded under CPT® 31781 is indicated for patients presenting with tracheal stenosis that extends into the distal third of the trachea. This condition may manifest as various symptoms, including:
The surgical procedure for CPT® 31781 involves several critical steps to ensure the successful excision of the tracheal stenosis and the anastomosis of the trachea. The following steps outline the procedure:
After the completion of the procedure, patients typically require close monitoring in a postoperative setting. Expected recovery may involve managing pain, monitoring respiratory function, and ensuring that there are no complications such as infection or airway obstruction. Patients may need to stay in the hospital for a few days for observation and to receive supportive care. Follow-up appointments will be necessary to assess the healing of the anastomosis and the overall function of the airway. Additional interventions may be required if complications arise or if the stenosis recurs.
| Short Descr | RECONSTRUCT WINDPIPE | Medium Descr | EXC TRACHEAL STENOSIS&ANAST CERVICOTHORACIC | Long Descr | Excision tracheal stenosis and anastomosis; cervicothoracic | 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 |
| 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). | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 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.) | 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 | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days |
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| Pre-1990 | Added | Code added. |
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