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A tracheal wound or injury refers to any damage or disruption to the trachea, which is the airway that connects the throat to the lungs. The repair of such an injury is critical to restore normal breathing and prevent complications such as airway obstruction or infection. The procedure described by CPT® Code 31800 specifically involves the suturing of a tracheal wound or injury located in the proximal or middle third of the trachea, utilizing a cervical approach. This means that the surgeon accesses the trachea through an incision in the neck. The complexity of the procedure can vary based on the specific characteristics of the wound or injury, including its size, location, and the presence of any associated structures that may be affected. The surgical approach requires careful dissection and retraction of surrounding anatomical structures, such as the thyroid isthmus and innominate vessels, to adequately expose the trachea for repair. The ultimate goal of this procedure is to ensure the integrity of the trachea is restored, allowing for proper airflow and minimizing the risk of further complications.
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The procedure described by CPT® Code 31800 is indicated for the repair of tracheal wounds or injuries that occur in the proximal or middle third of the trachea. These injuries may arise from various causes, including trauma, surgical complications, or penetrating injuries. The need for surgical intervention is typically determined by the severity of the injury, the patient's respiratory status, and the potential for airway compromise.
The procedure for suturing a tracheal wound or injury involves several critical steps to ensure proper repair and minimize complications. The following outlines the procedural steps as described in the CPT® data:
Post-procedure care following the suturing of a tracheal wound or injury is essential for recovery. Patients are typically monitored for respiratory function and any signs of complications, such as infection or airway obstruction. Depending on the extent of the injury and the surgical approach used, patients may require additional supportive care, including oxygen therapy or mechanical ventilation. Follow-up evaluations are necessary to assess the healing of the trachea and ensure that the airway remains patent. Patients may also be advised on activity restrictions and signs of complications to watch for during their recovery period.
| Short Descr | REPAIR OF WINDPIPE INJURY | Medium Descr | SUTURE TRACHEAL WOUND/INJURY CERVICAL | Long Descr | Suture of tracheal wound or injury; cervical | 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) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | 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 |
| 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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. | 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| Pre-1990 | Added | Code added. |
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