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2025 CPT code 31786

Excision of thoracic tracheal tumor or carcinoma.

Refer to CPT coding guidelines for accurate reporting of procedures on the trachea and bronchi.

Modifiers may be applicable. Check current CPT guidelines for appropriate use.

Medical necessity must be established by demonstrating the presence of a tracheal tumor requiring surgical intervention. Supporting documentation, including imaging and pathology reports, should be provided.

The provider diagnoses the tracheal tumor, performs the surgical excision, and repairs the trachea. They also manage pre- and post-operative care.

In simple words: The surgeon removes a tumor from the part of the windpipe in your chest. This involves making an incision, taking out the tumor and some surrounding tissue, and then fixing the area.

The provider excises a thoracic tracheal tumor. The patient is diagnosed with a neoplasm in the thoracic trachea (windpipe), which often presents with nonspecific symptoms like shortness of breath, coughing, or wheezing. Radiology and pathology tests confirm the presence and nature of the neoplasm. Bronchoscopy may be used to assess the lesion's extent. Under general anesthesia and in the supine position, the provider incises the thoracic trachea, excises the tumor and margins, and repairs the defect.The thoracic trachea is the part of the windpipe located in the posterior mediastinum, separated from the vertebrae by the esophagus. The mediastinum is the central part of the chest cavity.

Example 1: A patient with shortness of breath and coughing is found to have a benign tumor in their thoracic trachea. The surgeon performs a tracheal resection using code 31786., A patient with a malignant tracheal tumor undergoes excision of the tumor and a segment of the trachea, followed by reconstruction, using code 31786., A patient with a tracheal carcinoma requires removal of the tumor and surrounding tissue via an open surgical approach. The surgeon uses code 31786 for the procedure.

Documentation should include details of the diagnosis, pre-operative evaluation, operative report (including tumor size, location, margins), and post-operative care plan.

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