2025 CPT code 31780
Effective Date: N/A Surgery - Surgical Procedures on the Respiratory System Feed
Excision of tracheal stenosis and anastomosis; cervical
Modifiers may be applicable to 31780 in specific circumstances.For example, modifier -22 (Increased Procedural Services) might be used if the procedure was significantly more complex than usual. Modifier -51 (Multiple Procedures) would apply if other distinct procedures were performed during the same operative session.It's important to consult the appropriate coding guidelines and payer policies to determine correct modifier usage.
Medical necessity for 31780 is established when tracheal stenosis significantly impairs breathing and less invasive treatments have failed or are unsuitable.Documentation should clearly demonstrate the severity of the stenosis, its impact on the patient's respiratory function, and why surgery is the necessary course of treatment.
The surgeon is responsible for performing the tracheal resection and anastomosis, ensuring the integrity of the airway, and managing any potential complications. This includes careful dissection to avoid damage to surrounding structures such as the thyroid gland, major neck vessels, and recurrent laryngeal nerves. Post-operative care and monitoring are also part of the surgeon’s responsibility.
In simple words: The surgeon removes a narrowed section of the windpipe (trachea) in the neck and then sews the healthy parts back together to restore normal breathing.
The provider excises a narrowing of the trachea (tracheal stenosis) and then joins the tracheal segments (anastomosis) to repair the defect and reestablish the airway.The procedure typically involves making a cervical incision, carefully dissecting down to the trachea, excising the stenotic section, and then suturing the remaining tracheal segments together. A nasotracheal tube is usually inserted, the tracheostomy tube removed (if present), and the patient’s chin may be sutured to the anterior chest wall to reduce tension on the anastomosis.
Example 1: A patient with severe tracheal stenosis following prolonged intubation requires surgical intervention to restore adequate airflow., A patient with tracheal stenosis caused by trauma undergoes resection and anastomosis to repair the damaged trachea., A child with a congenital tracheal stenosis requires surgery to widen the narrowed segment and improve breathing.
Documentation should include the operative report detailing the procedure, the size and location of the stenosis, the length of trachea resected, the type of anastomosis performed, and any complications encountered. Pre- and post-operative imaging studies (e.g., X-rays, CT scans) should also be documented.Any prior treatments for the stenosis and the rationale for surgical intervention should be noted.
** For patients with stenosis of the cervical trachea related to prior intubation or tracheostomy, other related procedures often done during the same operative session (with the -51 multiple procedures modifier applied) would include suprahyoid release or laryngeal release procedures. For congenital tracheal stenosis, other related procedures might include tracheoplasty, aortopexy, or slide tracheoplasty.
- Specialties:Otolaryngology, Thoracic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center