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A tracheal wound or injury refers to any damage or disruption to the trachea, which is the airway passage that connects the throat to the lungs. The repair of such an injury is performed through suturing, a surgical technique that involves stitching the edges of the wound together to promote healing. The specific approach taken during the procedure is determined by the location and severity of the injury. For instance, when the injury occurs in the proximal or middle third of the trachea, a cervical approach is utilized, as described in CPT® Code 31800. In contrast, CPT® Code 31805 pertains to injuries located in the distal third of the trachea, necessitating an intrathoracic approach. This can be achieved through either an anterior or posterior method. The anterior approach typically involves a median sternotomy, where the chest is opened to access the trachea, while the posterior approach requires a right posterolateral thoracotomy, allowing access from the back. Both methods involve careful dissection and retraction of surrounding structures to expose the trachea adequately, ensuring that critical nerves and blood vessels are preserved during the procedure. The ultimate goal of the surgery is to repair the trachea effectively, ensuring the airway remains patent and functional following the injury.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 31805 is indicated for the repair of tracheal wounds or injuries specifically located in the distal third of the trachea. This may include situations where there is a traumatic injury, surgical complication, or other forms of damage that compromise the integrity of the trachea and require surgical intervention to restore normal airway function.
The procedure for suturing a tracheal wound or injury involves several critical steps, which are detailed as follows:
Following the completion of the tracheal repair, patients are typically monitored for any signs of complications, such as bleeding or infection. The recovery process may involve close observation in a hospital setting, especially if the injury was severe. Patients may require supplemental oxygen or other respiratory support during the initial recovery phase. Follow-up care is essential to ensure that the trachea heals properly and that the airway remains patent. Additional imaging or diagnostic procedures may be performed to assess the integrity of the repair and the overall function of the trachea.
| Short Descr | REPAIR OF WINDPIPE INJURY | Medium Descr | SUTURE TRACHEAL WOUND/INJURY INTRATHORACIC | Long Descr | Suture of tracheal wound or injury; 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 |
| 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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| Pre-1990 | Added | Code added. |
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