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The procedure described by CPT® Code 31786 involves the excision of a tumor or carcinoma located in the distal third of the trachea. The trachea, commonly known as the windpipe, is a vital airway structure that connects the throat to the lungs. Tumors or carcinomas in this area can obstruct airflow and lead to serious respiratory issues. The excision is performed using either an anterior or posterior intrathoracic approach, depending on the specific location and characteristics of the tumor. In the anterior approach, a median sternotomy is performed, which involves making an incision along the sternum to gain access to the thoracic cavity. This allows for the retraction of major blood vessels to expose the trachea and carina, which is the point where the trachea divides into the left and right main bronchi. Alternatively, the posterior approach utilizes a right posterolateral thoracotomy, which involves an incision on the side of the chest to access the trachea from behind. This approach requires careful dissection of surrounding structures, including the esophagus and mediastinal pleura, to ensure that the vagus and laryngeal nerves are protected during the procedure. The excision of the tumor is performed with a margin of healthy tissue to ensure complete removal, followed by suturing of the trachea and closure of the surgical incisions. This procedure is critical for patients with tracheal tumors, as it aims to remove malignant growths and restore normal airway function.
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The excision of a tracheal tumor or carcinoma, as described by CPT® Code 31786, is indicated for patients presenting with a tumor or carcinoma located in the distal third of the trachea. This procedure is typically performed when the tumor is causing symptoms such as airway obstruction, difficulty breathing, or other respiratory complications. The presence of malignancy in the trachea necessitates surgical intervention to remove the tumor and prevent further progression of the disease.
The procedure for excising a tracheal tumor or carcinoma involves several critical steps to ensure successful removal and patient safety.
Post-procedure care following the excision of a tracheal tumor or carcinoma is essential for patient recovery. Patients are typically monitored for respiratory function and any signs of complications, such as bleeding or infection. Pain management is provided as needed, and patients may require supplemental oxygen to assist with breathing during the initial recovery phase. Follow-up appointments are crucial to assess the surgical site and ensure proper healing. Additionally, further treatment options, such as radiation or chemotherapy, may be discussed based on the pathology results of the excised tumor.
| Short Descr | REMOVE WINDPIPE LESION | Medium Descr | EXCISION TRACHEAL TUMOR/CARCINOMA THORACIC | Long Descr | Excision of tracheal tumor or carcinoma; thoracic | 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. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery |
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