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A tracheostomy or tracheal fistula is a surgical opening created in the trachea, typically for the purpose of providing an airway for patients who have difficulty breathing. In many cases, these openings can close spontaneously after the removal of the tracheostomy tube. However, when the opening fails to close on its own, surgical intervention becomes necessary to ensure proper healing and to prevent complications such as infection or airway obstruction. The procedure described by CPT® Code 31825 involves the surgical closure of a tracheostomy or tracheal fistula using advanced plastic repair techniques. Unlike the simpler closure method outlined in CPT® Code 31820, which involves direct closure without plastic repair, CPT® Code 31825 employs more sophisticated methods to enhance the aesthetic and functional outcomes of the closure. This includes excising the epithelialized skin tract, incising and undermining the surrounding skin to relieve tension, and utilizing various plastic surgery techniques to minimize scarring. Techniques such as de-epithelialization, dermal-fat-fascia grafts, or acellular dermal grafts may be employed to achieve a more favorable cosmetic result while ensuring the integrity of the closure. The goal of this procedure is not only to close the opening effectively but also to ensure that the resulting scar is as inconspicuous as possible, ideally aligning it with existing skin folds.
© Copyright 2025 Coding Ahead. All rights reserved.
The surgical closure of a tracheostomy or tracheal fistula using CPT® Code 31825 is indicated in the following situations:
The procedure for the surgical closure of a tracheostomy or tracheal fistula involves several detailed steps:
After the surgical closure of a tracheostomy or tracheal fistula, patients are typically monitored for any signs of complications, such as infection or respiratory distress. Post-operative care may include pain management, wound care instructions, and follow-up appointments to assess healing. Patients are advised to avoid strenuous activities during the initial recovery period to ensure proper healing of the surgical site. The expected recovery time may vary depending on individual circumstances, but close monitoring and adherence to post-operative guidelines are essential for optimal outcomes.
| Short Descr | REPAIR OF WINDPIPE DEFECT | Medium Descr | SURG CLSR TRACHEOSTOMY/FISTULA W/PLASTIC RPR | Long Descr | Surgical closure tracheostomy or fistula; with plastic repair | 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 | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | 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. | 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.) | 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.) | 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 | GW | Service not related to the hospice patient's terminal condition |
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| Pre-1990 | Added | Code added. |
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