Summary & Overview
CPT 31613: Revision of Tracheostomy Stoma Without Flap Rotation
CPT code 31613 denotes a surgical revision of a tracheostomy stoma performed without flap rotation. Nationally, this code is used to report focused operative correction of the tracheal stoma when tissue rotation techniques are not employed. It matters because accurate coding supports clinical tracking of tracheostomy care, informs surgical quality measures, and affects hospital and surgical center billing across payers. Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will gain a concise clinical context for when CPT code 31613 is appropriate, understand the typical service setting (operating room or outpatient surgical center), and find guidance on what to expect in benchmarking and policy-related discussions. The summary highlights common modifiers associated with procedural reporting and notes where input data were not provided. This national overview assists coding professionals, surgical teams, and revenue cycle staff in recognizing the procedure’s scope and in preparing for payer-specific documentation and claims processes.
Billing Code Overview
CPT code 31613 describes a revision of a tracheostomy stoma without flap rotation, a surgical procedure to revise the opening into the trachea. This procedure focuses on correcting or improving the stoma itself without rotating local tissue flaps.
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Service type: Surgical revision of tracheostomy stoma
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Typical site of service: Operating room or other surgical setting (inpatient or outpatient surgical center)
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is a 62-year-old with a longstanding tracheostomy who presents with a stenotic or malformed tracheostoma causing airway obstruction, poor prosthetic fit, recurrent tracheostomy-related infection, or persistent peristomal granulation tissue. Preoperative assessment includes airway evaluation, review of prior operative reports and tracheostomy tube history, pulmonary and anesthesia risk assessment, and obtaining informed consent. In the operating room or ambulatory surgical center with monitored anesthesia (general or deep sedation), the surgeon exposes the stoma, excises scar tissue, revises the tracheal mucosal edge and skin edges without flap rotation to restore a patent, well-shaped stoma. Hemostasis is achieved, tracheostomy tube position verified, and postoperative instructions include stoma care, suctioning guidance, and follow-up for decannulation planning or further reconstruction if needed.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Indicates the office or outpatient service was performed by the billing provider | Use when this procedure is performed by the primary surgeon who reports the service. |
22 | Increased procedural services |