🧬CPT 31600 — Tracheostomy, Planned (Separate Procedure)

Code Description

Official CPT Description: Tracheostomy, planned (separate procedure)

CPT 31600 reports an open, surgically planned tracheostomy performed on a patient age two years or older. The procedure creates a direct, surgically constructed airway opening through the anterior neck and into the trachea, resulting in either temporary or permanent access to the airway below the level of the larynx. The word “planned” in the descriptor is essential — it distinguishes this code from emergency tracheostomy codes (31603, 31605) and signals an elective or semi-elective procedure performed under controlled, non-emergent conditions.

The “separate procedure” designation in the descriptor is equally critical and represents one of the most important coding compliance considerations associated with this code. Under CPT guidelines, a procedure labeled “separate procedure” should not be reported when it is performed as a routine component of a more extensive procedure within the same anatomic region during the same operative session. However, when a planned tracheostomy is performed at a distinct anatomic site or is not an integral component of the concurrent procedure, it may be separately reported.

CPT 31600 is specifically for the open surgical approach in patients age two and older. Percutaneous dilational tracheostomy (PDT), which is commonly performed at the bedside in the ICU by critical care physicians and pulmonologists, does not have its own dedicated adult CPT code. Per AMA CPT Assistant guidance and prevailing coding convention, CPT 31601 (tracheostomy, planned; younger than 2 years) is the correct code for all percutaneous dilational tracheostomies regardless of patient age. This is one of the most consequential and frequently misunderstood coding rules in the entire tracheostomy code family.

Anatomy & Clinical Context

The trachea is a cartilaginous and membranous tube approximately 10-12 cm in length in adults, beginning at the inferior border of the cricoid cartilage (approximately C6) and descending to the carina at the level of the sternal angle (T4/T5), where it bifurcates into the right and left main bronchi. It is composed of 16-20 incomplete (C-shaped) hyaline cartilage rings anterolaterally, with a flat posterior membranous wall composed of trachealis muscle and connective tissue.

A tracheostomy creates a surgical fistula from the anterior neck skin surface through the pre-tracheal soft tissue and anterior tracheal wall, establishing a patent airway channel. Typically, this opening is created between the 2nd and 4th tracheal rings to minimize the risk of subglottic stenosis (which increases when the stoma is too high) or innominate artery erosion (which increases when the stoma is too low). A tracheostomy tube — cuffed, uncuffed, fenestrated, or non-fenestrated — is placed into the newly created stoma to maintain airway patency.

The distinction between a tracheotomy (an incision into the trachea) and a tracheostomy (a surgically created stoma between the tracheal lumen and the skin surface) is often used interchangeably in clinical practice, though technically tracheostomy implies a mature, maintained opening. For coding purposes, both terms map to the same CPT code.

Common clinical indications for a planned tracheostomy include:

Prolonged mechanical ventilation dependence (typically when the patient has been intubated for 10 or more days and is not expected to be weaned in the short term)
Upper airway obstruction from neoplasm (laryngeal, hypopharyngeal, oral cavity, or neck mass)
Airway protection in patients with compromised swallow function or aspiration risk (ALS, stroke, traumatic brain injury, severe dementia)
Bilateral vocal cord paralysis causing chronic airway obstruction
Subglottic or tracheal stenosis requiring bypass of the obstructed segment
Pre-operative airway access before major head and neck surgery involving the larynx, pharynx, or oral cavity
Trauma to the face, neck, or airway requiring an alternative airway
Sleep apnea refractory to all other treatments (rarely performed for this indication today)
Burns or angioedema causing progressive airway compromise

Procedure Overview

Open Surgical Approach (CPT 31600):

The patient is positioned supine with the neck extended using a shoulder roll to bring the trachea anteriorly and closer to the skin surface. General anesthesia is induced and the patient is orally intubated.
A horizontal or vertical skin incision is made approximately 2-3 cm below the inferior border of the cricoid cartilage at the level of the 2nd and 3rd tracheal rings. A horizontal (Bjork-style) incision provides better cosmesis; a vertical incision may be used in obese or short-necked patients.
Subcutaneous tissue is divided and the strap muscles (sternohyoid, sternothyroid) are separated vertically in the midline using blunt dissection to expose the pre-tracheal fascia.
The thyroid isthmus is identified. If it overlies the desired tracheostomy site, it is divided between clamps and ligated, or retracted superiorly or inferiorly as needed. (Note: division of the thyroid isthmus is included in 31600 and is not separately reportable, despite occasional debate.)
The pre-tracheal fascia is incised and the anterior tracheal wall is exposed. Stay sutures are placed in the tracheal cartilage rings to facilitate tube reinsertion if needed.
A tracheal incision is created using one of several techniques: horizontal incision between rings (most common), Bjork flap (inferior-based tracheal flap sutured to the skin), vertical incision through two rings, or a controlled punch excision of an anterior tracheal window.
The oral endotracheal tube is withdrawn by anesthesia until the tip is just above the incision site under direct visualization.
The appropriate tracheostomy tube (typically a cuffed, non-fenestrated tube for immediate post-operative use) is inserted into the tracheal lumen, the cuff is inflated, and correct positioning is confirmed by capnography and equal breath sounds.
The tube is secured with ties or sutures to prevent accidental decannulation.

Percutaneous Dilational Technique (reported as CPT 31601 per AMA guidelines — NOT 31600):

The Seldinger technique is used. The trachea is accessed percutaneously via a needle between the 1st and 2nd or 2nd and 3rd tracheal rings, a guidewire is inserted, and progressive dilation is performed using a series of dilators (Ciaglia blue rhino, Ciaglia multiple dilators, Griggs forceps, or other PDT systems) until the stoma is large enough to accept the tracheostomy tube. This technique does not involve open dissection and is typically performed at the ICU bedside under flexible bronchoscopic guidance.

ICD-10-CM Diagnosis Codes

The following diagnosis codes represent the most clinically relevant indications supporting medical necessity for CPT 31600. The appropriate code selection depends on the underlying reason the tracheostomy is being performed. The tracheostomy itself is a procedure, not a diagnosis — always code the underlying condition requiring the tracheostomy rather than the tracheostomy as the diagnosis.

Respiratory Failure / Ventilator Dependence

J96.00 — Acute respiratory failure, unspecified whether with hypoxia or hypercapnia. The most frequent indication when the tracheostomy is being placed due to inability to wean from mechanical ventilation.
J96.01 — Acute respiratory failure with hypoxia.
J96.02 — Acute respiratory failure with hypercapnia.
J96.10 — Chronic respiratory failure, unspecified. Tracheostomy for long-term ventilator management in a patient with chronic respiratory failure.
J96.11 — Chronic respiratory failure with hypoxia.
J96.20 — Acute and chronic respiratory failure, unspecified.

Airway Obstruction — Laryngeal/Tracheal

J38.6 — Stenosis of larynx. Tracheostomy to bypass a critically narrowed laryngeal airway.
J38.01 — Paralysis of vocal cords and larynx, unilateral.
J38.02 — Paralysis of vocal cords and larynx, bilateral. Bilateral vocal cord paralysis causing stridor and severe upper airway obstruction is a classic indication for emergent or planned tracheostomy.
J38.7 — Other diseases of larynx. Covers tracheomalacia, laryngeal web, laryngeal granuloma, and other structural laryngeal pathology causing obstruction.
J95.5 — Postprocedural subglottic stenosis. A tracheostomy performed as airway bypass for stenosis that developed as a complication of prior intubation or prior tracheal surgery.
J39.8 — Other specified diseases of upper respiratory tract. Includes tracheal stenosis not elsewhere classified.
Q32.1 — Congenital tracheal stenosis (use 31601 in patients under 2 years).

Head and Neck Malignancy

C32.0 — Malignant neoplasm of glottis.
C32.1 — Malignant neoplasm of supraglottis.
C32.9 — Malignant neoplasm of larynx, unspecified. Tracheostomy as part of planned laryngectomy or as preliminary airway access before total laryngectomy.
C10.9 — Malignant neoplasm of oropharynx, unspecified.
C09.9 — Malignant neoplasm of tonsil, unspecified.
C14.8 — Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx.
C14.0 — Malignant neoplasm of pharynx, unspecified.
C34.10-C34.92 — Malignant neoplasm of bronchus and lung. tracheostomy may be performed as part of management when tumor involves the trachea or when airway access is required for pulmonary toilet in severe lung cancer.
C73 — Malignant neoplasm of thyroid gland. Large thyroid masses causing tracheal deviation and compression requiring tracheostomy for airway access.

Neurological Impairment

G12.21 — Amyotrophic lateral sclerosis. Progressive bulbar and respiratory failure eventually requiring long-term ventilatory support via tracheostomy.
G35.- — Multiple sclerosis with severe respiratory involvement.
G09 — Sequelae of inflammatory CNS disease with respiratory failure.
S14.109A — Unspecified injury of cervical spinal cord, initial encounter. High cervical spinal cord injury causing respiratory paralysis.
G83.84 — Diaphragmatic paralysis. When diaphragmatic failure results in chronic ventilator dependence.

Infection / Abscess

J39.0 — Retropharyngeal and parapharyngeal abscess. Deep neck space infections causing progressive airway compromise may require tracheostomy for airway protection.
J36 — Peritonsillar abscess. Rarely, severe bilateral peritonsillar abscess can cause airway compromise requiring tracheostomy.
J85.1 — Abscess of lung with pneumonia. Pulmonary sepsis with respiratory failure requiring long-term ventilatory support.

Trauma

S19.9XXA — Unspecified injury of neck, initial encounter. Penetrating or blunt neck trauma disrupting the airway.
S09.90XA — Unspecified injury of head, initial encounter. Severe TBI with loss of airway protective reflexes.
T07.XXXA — Unspecified multiple injuries. Major polytrauma with respiratory failure.
S27.0XXA — Traumatic pneumothorax, initial encounter. Thoracic trauma with associated respiratory failure.

Status/Administrative Codes (always secondary when applicable)

Z93.0 — Tracheostomy status. Reported at subsequent encounters when the tracheostomy remains in place. Not used at the encounter when the tracheostomy is created.
Z99.11 — Dependence on respirator (ventilator) status. Always captured as a secondary diagnosis when ventilator dependence is present.

ICD-10-PCS Crosswalk (Inpatient Facility)

In the inpatient setting, CPT codes are not assigned — ICD-10-PCS procedure codes are used for all claim and reporting purposes. The correct ICD-10-PCS code for a tracheostomy is built from the Medical and Surgical (0) section, Respiratory System (B) body system, with a root operation of Bypass (1) acting on body part Trachea (1).

The PCS logic for tracheostomy is that the procedure bypasses the trachea to a cutaneous (skin surface) destination — rerouting airflow through the anterior neck stoma rather than through the native upper airway passage. The qualifier character 4 (Cutaneous) is always used as the destination.

Character Structure for Tracheostomy PCS Codes:

Section: 0 (Medical and Surgical)
Body System: B (Respiratory System)
Root Operation: 1 (Bypass)
Body Part: 1 (Trachea)
Approach: 0 (Open), 3 (Percutaneous), or 4 (Percutaneous Endoscopic)
Device: F (Tracheostomy Device) or Z (No Device)
Qualifier: 4 (Cutaneous)

Open Surgical Tracheostomy (matches CPT 31600):

0B110F4 — Bypass Trachea to Cutaneous with Tracheostomy Device, Open Approach. This is the primary PCS code corresponding to a standard open tracheostomy with tube placement (CPT 31600).
0B110Z4 — Bypass Trachea to Cutaneous, Open Approach (no device). Used in the rare circumstance where the trachea is bypassed to the skin without leaving a tube in place — such as a temporary tracheostomy with immediate closure without tube placement. This is unusual.

Percutaneous Tracheostomy (PDT — maps to CPT 31601 per coding convention):

0B113F4 — Bypass Trachea to Cutaneous with Tracheostomy Device, Percutaneous Approach. This is a non-OR designated code in the MS-DRG grouper. When 0B113F4 is assigned alone, it does not trigger a surgical DRG.
0B113Z4 — Bypass Trachea to Cutaneous, Percutaneous Approach (no device). Also non-OR.
0B114F4 — Bypass Trachea to Cutaneous with Tracheostomy Device, Percutaneous Endoscopic Approach. This code is OR-designated in the MS-DRG grouper, unlike 0B113F4. It is used when bronchoscopic guidance was used during PDT and the bronchoscope itself constitutes the “endoscopic” approach qualifier.
0B114Z4 — Bypass Trachea to Cutaneous, Percutaneous Endoscopic Approach (no device).

Critical PCS Coding Nuance — Percutaneous vs. Percutaneous Endoscopic: This distinction has significant DRG impact. When a PDT is performed with bronchoscopic guidance (which is the standard of care at most institutions), the approach character should be 4 (Percutaneous Endoscopic) — code 0B114F4 — because the endoscope provides direct visualization of the tracheal puncture site from within. Code 0B114F4 is OR-designated and will trigger a surgical DRG (DRG 004 or potentially DRG 003 in conjunction with extended ventilation). When bronchoscopic guidance is not used, the approach is 3 (Percutaneous) — code 0B113F4 — which is a non-OR procedure. Always review the operative note to confirm whether bronchoscopic guidance was used. This single character difference can move a claim from a medical DRG to a high-weight surgical DRG worth potentially thousands of additional dollars in reimbursement to the facility.

ICD-10-PCS for Tracheal Resection/Reconstruction (distinguish from simple tracheostomy): If the trachea was resected and the tracheostomy is created as part of a laryngectomy or tracheal resection, the PCS table entries for Excision (B) or Resection (T) of the trachea apply in addition to the Bypass code. For total laryngectomy with tracheostomy, a permanent tracheostomy stoma is not a tube but a surgically constructed end-tracheal stoma sutured to the skin — still coded as Bypass to Cutaneous.

MS-DRG Assignment

The DRG assignment for inpatient cases involving tracheostomy is among the most complex and highest-stakes grouping logic in the entire MS-DRG system. Tracheostomy cases are processed through a Pre-MDC logic before any standard MDC classification occurs — meaning that the presence of a qualifying tracheostomy procedure code can override normal MDC grouping and redirect the case to specialized, typically very high-weight DRGs.

Pre-MDC Tracheostomy DRGs (highest priority — evaluated before MDC assignment):

MS-DRG 003 — ECMO or Tracheostomy with MV >96 Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. Procedures. This is one of the highest-weighted DRGs in the entire MS-DRG system, with a relative weight above 16.0 and geometric mean LOS of approximately 30 days. It is triggered when a qualifying tracheostomy PCS code is present AND the patient either (a) received mechanical ventilation for more than 96 consecutive hours (5A1955Z), OR (b) the principal diagnosis is not a face, mouth, or neck diagnosis, AND a major O.R. procedure is also coded.
MS-DRG 004 — Tracheostomy with MV >96 Hours or PDX Except Face, Mouth and Neck without Major O.R. Procedure. Similar logic to DRG 003 but without a major O.R. procedure present. Also extremely high-weight.

Face, Mouth and Neck Tracheostomy DRGs (for head and neck principal diagnoses):

When the principal diagnosis IS a face, mouth, or neck diagnosis (e.g., laryngeal cancer, oropharyngeal cancer, deep neck infection, neck trauma), the case is directed to the face, mouth and neck tracheostomy DRGs rather than the Pre-MDC DRGs:

MS-DRG 011 — Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with MCC. High-weight DRG reflecting medically complex head and neck oncology patients.
MS-DRG 012 — Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with CC.
MS-DRG 013 — Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy without CC/MCC.

Respiratory Surgical DRGs (when tracheostomy does not reach DRG 003/004/011-013 threshold):

MS-DRG 166 — Other Respiratory System O.R. Procedures with MCC
MS-DRG 167 — Other Respiratory System O.R. Procedures with CC
MS-DRG 168 — Other Respiratory System O.R. Procedures without CC/MCC

Key Grouping Logic Summary for Inpatient Coders:

The most important question is: Does the case qualify for DRG 003 or 004? This determination hinges on three factors that must be evaluated simultaneously:

Is a qualifying tracheostomy PCS code present? (0B110F4, 0B114F4, and certain others qualify — notably 0B113F4 does NOT trigger Pre-MDC grouping as it is non-OR designated)
Is mechanical ventilation greater than 96 consecutive hours present? (ICD-10-PCS 5A1955Z — Respiratory Ventilation, Greater than 96 Consecutive Hours)
Is the principal diagnosis a face, mouth, or neck diagnosis? (If yes → DRGs 011-013; if no → DRGs 003-004)

If the answer to question 1 is yes and the answer to question 2 is yes, and the principal diagnosis is not a face/mouth/neck condition, the case will almost certainly group to DRG 003 (with major O.R.) or DRG 004 (without major O.R.) — both of which carry among the highest relative weights in the entire IPPS system. The difference between DRG 003 and DRG 004 depends on whether any other major O.R. procedure (e.g., coronary artery bypass, bowel resection, orthopedic hardware placement) is also present on the claim.

Accurate capture of ventilator hours via 5A1955Z is therefore one of the most financially consequential coding decisions associated with tracheostomy cases. Missing this code when mechanical ventilation clearly exceeded 96 hours can result in the case grouping to a dramatically lower-weighted DRG, representing a major revenue integrity failure.

wRVU and Reimbursement

Work RVU (wRVU): 5.56
Total RVU (facility): approximately 8.97
Global Period: 0 days under Medicare. Some commercial payers impose a 15-day global period — always verify with individual payer contracts. The 0-day global under Medicare means any post-operative visits (including bedside stoma care, trach tube evaluations, or follow-up E/M visits) are separately billable on the day after surgery and beyond.
2025 Medicare Conversion Factor: $32.35
Approximate 2025 Medicare Facility Payment: ~ $290 -$ 325
Approximate 2025 Medicare Non-Facility Payment: ~ $440 -$ 480
Anesthesia Code Crosswalk: 00320 (Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified, age 1 year and older) — 5 base units

The wRVU of 5.56 reflects a moderately complex surgical procedure. By comparison, CPT 31601 (tracheostomy, planned; younger than 2 years, or percutaneous dilational in any age patient) carries a wRVU of approximately 8.00, reflecting the greater technical complexity of neonatal/infant airway surgery and/or percutaneous technique. CPT 31603 (emergency tracheostomy, transtracheal) carries approximately 6.00 wRVU, reflecting the added complexity and risk associated with an emergent scenario.

Commercial Payer Global Period Warning: Unlike Medicare’s 0-day global, some Blue Cross, UHC, Aetna, and regional payer contracts still impose a 15-day global period on 31600. During a 15-day global period, routine post-operative visits by the performing surgeon are included in the surgical payment and cannot be separately billed. E/M visits for unrelated conditions during this window are still separately payable with Modifier 24. Coders and billers should maintain a payer-specific global period reference table for tracheostomy codes.

Assistant Surgeon

CPT 31600 has an assistant surgeon indicator of 1 under Medicare — meaning that an assistant surgeon may be payable when medical necessity is documented. Unlike many simpler ENT procedures where assistant surgery is categorically not permitted (indicator 0), tracheostomy involves sufficient anatomic complexity, risk, and the potential need for a second operator that Medicare recognizes assistant surgeon billing as appropriate in qualifying cases.

Modifier -80 — Assistant Surgeon. Used when a qualified physician serves as the formal second operative surgeon.
Modifier -82 — Assistant Surgeon (when qualified resident surgeon is not available). Used at teaching hospitals when the normal expectation would be a resident assistant, but none is available. Documentation of resident unavailability is required.
Modifier -81 — Minimum Assistant Surgeon. Used when the assistant’s role is limited (e.g., retraction, suctioning) and does not constitute full assistant surgeon participation.

Medicare reimburses the assistant surgeon at 16% of the primary surgeon’s allowed amount. Commercial payer policies vary widely. Not all commercial plans recognize Modifier 80 assistant surgeon billing for 31600 — payer-specific policy verification is essential before billing.

Cases most likely to support assistant surgeon billing include: morbidly obese patients with short/thick necks, revision tracheostomy after prior stoma complications, concurrent major head and neck oncologic surgery, trauma cases with complex neck anatomy, and pediatric or neonatal cases (though those would use 31601).

HCC Relevance

CPT 31600 itself is a procedure code and carries no direct HCC mapping. However, the clinical circumstances surrounding tracheostomy placement are almost universally associated with diagnoses that carry significant HCC weight. Tracheostomy patients represent some of the most medically complex patients in any inpatient setting, and thorough, accurate diagnosis capture is not only important for DRG weight optimization but also for risk-adjustment accuracy.

High-Weight HCC Codes Frequently Associated with 31600 Encounters:

J96.00 / J96.01 / J96.02 — Acute Respiratory Failure → HCC 84 (Cardiorespiratory Failure and Shock). One of the highest-weight HCC categories in the CMS-HCC model.
G12.21 — ALS → HCC 75 (Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome; Inflammatory and Toxic Neuropathy). High-weight HCC reflecting terminal progressive disease.
C32.x — Laryngeal Malignancy → HCC 10 (Lymphatic, Head and Neck, Brain, and Other Major Cancers). High-weight cancer HCC.
C10.9, C14.x — Oropharyngeal/Head and Neck Malignancy → HCC 10. High-weight.
S14.109A — Cervical spinal cord injury → HCC 70/71 (Quadriplegia/Paraplegia). Extremely high-weight.
J44.1 — COPD with acute exacerbation → HCC 111. Moderate weight.
Z99.11 — Ventilator dependence → not itself HCC-mapped, but always accompanied by underlying HCC-mapped diagnoses.
Z93.0 — Tracheostomy status → not HCC-mapped, but signals a high-complexity patient.

The aggregate HCC burden in a typical 31600 patient is substantial. Comprehensive secondary diagnosis capture — including all comorbidities actively managed during the stay — is essential for accurate CMS risk scores and appropriate resource intensity documentation.

Understanding the full tracheostomy code family and its neighboring procedures is critical for selecting the correct code and avoiding both undercoding and overcoding.

Incision Procedures on the Trachea and Bronchi — CPT 31600-31614 │ ├── TRACHEOSTOMY — PRIMARY CODES │ ├── 31600 — Tracheostomy, planned (separate procedure); age 2+ ← THIS CODE │ │ wRVU 5.56 | 0-day global (Medicare) | Open approach │ │ Also used for: open tracheostomy in adult │ │ │ ├── 31601 — Tracheostomy, planned (separate procedure); younger than 2 years │ │ wRVU ~8.00 | 0-day global (Medicare) | ALSO used for ALL percutaneous │ │ dilational tracheostomies (PDT) in patients of any age per AMA guidance │ │ │ ├── 31603 — Tracheostomy, emergency procedure; transtracheal │ │ wRVU ~6.00 | 0-day global | Emergent open approach, not cricothyroid │ │ │ ├── 31605 — Tracheostomy, emergency procedure; cricothyroid membrane │ │ wRVU ~5.00 | 0-day global | Emergent cricothyrotomy │ │ │ └── 31610 — Tracheostomy, fenestration procedure with skin flaps │ wRVU varies | Permanent tracheostomy with planned epithelialization │ ├── TRACHEOSTOMY TUBE MANAGEMENT │ └── 31502 — Tracheotomy tube change prior to establishment of fistula tract │ wRVU ~1.00 | Only reportable during the first 7-10 days post-tracheostomy │ before the tract has matured. After fistula formation, tube changes │ are NOT separately billable and are included in any related E/M. │ ├── LARYNX/TRACHEA INCISION — RELATED BUT DISTINCT │ ├── 31300 — Laryngotomy; thyrotomy, inferior constrictor myotomy │ ├── 31360 — Laryngectomy; total, without radical neck dissection │ ├── 31365 — Laryngectomy; total, with radical neck dissection │ └── 31367-31382 — Partial laryngectomy procedures │ ├── SUBSEQUENT TRACHEOBRONCHOSCOPY │ └── 31615 — Tracheobronchoscopy through established tracheostomy incision │ (Performed after tracheostomy is mature; wRVU 2.09; 0-day global) │ Separately reportable — not bundled with 31600 once the stoma is established │ ├── FREQUENTLY COMBINED HEAD AND NECK CODES │ ├── 38724 — Cervical lymph node dissection (selective) │ ├── 38720 — Cervical lymph node dissection (radical) │ ├── 42425 — Parotidectomy, total │ ├── 60240 — Thyroidectomy, total or complete │ │ NOTE: 31600 is NOT separately reportable with 60240 (same anatomic │ │ region — separate procedure rule applies) │ ├── 60500 — Parathyroidectomy or exploration of parathyroid(s) │ │ NOTE: Same separate procedure bundling concern as 60240 │ └── 30520 — Septoplasty (entirely different anatomic site — no bundling conflict) │ └── ICD-10-PCS EQUIVALENT CODES (inpatient facility — see crosswalk section above) ├── 0B110F4 — Open Approach with Tracheostomy Device (primary inpatient code) ├── 0B113F4 — Percutaneous, with device (non-OR; no DRG 003/004 trigger alone) └── 0B114F4 — Percutaneous Endoscopic, with device (OR; triggers DRG 003/004 when MV >96h)

Includes / What This Code Covers

Open surgical tracheostomy performed on a patient age 2 years or older under controlled, planned conditions
Division or retraction of the thyroid isthmus as required for tracheal access — this is considered a routine component of the tracheostomy procedure and is included in 31600. It is NOT separately reportable as a thyroid isthmus procedure, despite occasional provider insistence to the contrary.
Placement of the tracheostomy tube into the surgically created stoma (included; the tube itself may be separately reported as a supply using HCPCS codes A7520 or A7521 depending on the tube type)
Initial tracheostomy dressing and immediate post-procedure management on the day of surgery
All pre-operative patient preparation and immediate intraoperative anesthesia coordination related to the tracheostomy itself
Concurrent laryngoscopy used to facilitate positioning and confirm correct tracheostomy placement — per CMS NCCI policy, laryngoscopy performed solely to assist in placing a tracheostomy is included in 31600 and not separately reportable
Routine post-operative care on the day of the procedure (under the 0-day global)
Placement of stay sutures or tracheal retention sutures as part of the tracheostomy construction

Excludes / What This Code Does NOT Cover

Percutaneous dilational tracheostomy (PDT) in any patient — report as 31601 per AMA CPT Assistant guidance, regardless of the patient’s age. Reporting PDT as 31600 is a miscoding error.
Tracheostomy in a patient younger than 2 years — always use 31601, regardless of the surgical approach.
Emergency tracheostomy — use 31603 (transtracheal approach) or 31605 (cricothyroid membrane approach). The distinction between “planned” and “emergency” is determined by the clinical circumstances, not the approach — if the procedure was performed under urgently emergent conditions (patient decompensating, imminent loss of airway), the emergency code is more appropriate even if some preparation was possible.
Laryngectomy — total or partial laryngectomy with concurrent tracheostomy is reported using the laryngectomy codes (31360, 31365, etc.). The tracheostomy created at the time of laryngectomy is included in the laryngectomy code.
Thyroidectomy performed during the same session at the same site — 31600 is a “separate procedure” and is included when performed as a necessary component of thyroidectomy (60240) or parathyroidectomy (60500) at the same operative session. Do not separately report 31600 with these codes if the tracheostomy was part of gaining access or managing the airway during the same neck procedure.
Tracheostomy tube change after establishment of the fistula tract (after approximately 7-10 days) — not separately billable at any point once the tract is mature. Only 31502 (tube change prior to fistula establishment) is separately reportable, and only within the narrow early window.
Post-operative routine stoma care — stoma cleaning, humidification instruction, inner cannula cleaning, and routine tube management during the global period (if any applies under commercial payers) are not separately reportable.
Tracheobronchoscopy (31615) performed through the established tracheostomy at a later date — this is a separately billable procedure under its own CPT code, not included in the 31600 global period under Medicare (0-day global). Under commercial plans with a 15-day global, however, a 31615 performed within that window by the same surgeon would be considered bundled unless a separate indication existed.

NCCI Edits and Bundling Considerations

31600 and laryngoscopy (31515-31578): Per the CMS NCCI policy manual, laryngoscopy performed as part of or to facilitate tracheostomy placement is not separately reportable. The laryngoscopy is considered included within 31600. This is explicitly stated in the Medicare NCCI policy guidelines and overrides billing of laryngoscopy add-on or companion codes when the only clinical purpose of the scope was to assist with the trach.
31600 and thyroidectomy/parathyroidectomy (60240, 60500): The “separate procedure” designation in 31600’s descriptor means it should not be reported concurrently with related neck procedures at the same anatomic site in the same session. However, if the tracheostomy was performed for an entirely separate indication (e.g., airway protection due to laryngeal cancer) at a distinct anatomic site from the thyroid/parathyroid surgery, Modifier 59 or XS may allow separate billing with appropriate documentation.
31600 and laryngectomy (31360-31382): The tracheostomy created at the time of laryngectomy is integral to the laryngectomy and is not separately reportable. A permanent tracheostomy stoma is a required component of total laryngectomy.
31600 and 31603/31605: These codes are mutually exclusive — only one tracheostomy code can be reported per patient per encounter.
31600 and 31502 (tube change prior to fistula establishment): If a tube change is performed immediately after the original tracheostomy (e.g., within the same operative session due to tube displacement), it would be considered incidental and included. A tube change in a separate subsequent encounter during the first 7-10 days before tract formation is reportable with 31502.
31600 and E/M on the same date: Under the 0-day Medicare global, the operative day E/M is included. However, on subsequent days (day 1 and beyond), the performing surgeon may bill E/M visits separately, as there is no extended global period. This is a significant practice management point for ICU-based providers who frequently see their tracheostomy patients daily.

Modifiers

-22 (Increased Procedural Services) — May be applied when the work required was substantially greater than typically expected. Documented indications include: morbid obesity with extremely difficult neck anatomy, calcified tracheal cartilages, prior neck irradiation causing dense scarring, revision of a failed or infected prior tracheostomy, or complex concurrent anatomic anomalies. Must be accompanied by a cover letter to the payer explaining the exceptional circumstances and the additional time/complexity.
-51 (Multiple Procedures) — Applied to 31600 (typically as the secondary procedure) when billed alongside a more definitive concurrent procedure. Reduces reimbursement for secondary procedures per the multiple procedure reduction schedule.
-58 (Staged or Related Procedure During the Postoperative Period) — Applied when 31600 is performed during the global period of a prior procedure as a planned staged component of ongoing surgical management. Example: a patient undergoes major head/neck cancer resection under a 90-day global period and then returns to the OR during that global for a planned tracheostomy. Modifier 58 appended to 31600 indicates the tracheostomy was a planned staged component, allowing separate reimbursement.
-78 (Unplanned Return to OR for Related Procedure During Postoperative Period) — Applied when 31600 is performed as an unplanned return to the OR during another procedure’s global period due to a complication. Example: a patient develops acute respiratory failure and requires emergent tracheostomy during the global period of a prior unrelated abdominal surgery.
-79 (Unrelated Procedure During Postoperative Period) — Applied when 31600 is performed for an indication entirely unrelated to the procedure defining the active global period. Example: a patient with an active 90-day global from a splenectomy develops a new diagnosis of laryngeal cancer and undergoes planned tracheostomy for airway management.
-80 (Assistant Surgeon) — For the assistant surgeon’s claim. The assistant surgeon bills 31600-80 at 16% of the allowed amount.
-82 (Assistant Surgeon When Resident Not Available) — Used at teaching institutions when no qualified resident was available to assist, and a non-resident physician served as the assistant.

Documentation Requirements

The operative note must clearly support the assignment of CPT 31600 over any alternative code. The following elements are essential:

Surgical approach — explicit statement that an open surgical technique was used (incision, soft tissue dissection, exposure of trachea). If PDT was performed, documentation of “percutaneous,” “Seldinger technique,” “needle and guidewire,” or similar language directs the coder to 31601.
Patient age — for patients under 2 years, only 31601 applies. Patient demographics in the face sheet confirm age, but the operative note should also document the pediatric context if relevant.
Planned vs. emergency nature — the clinical circumstances and the pre-operative assessment should establish that this was a planned, elective, or semi-elective procedure, not an emergency. If the procedure was performed urgently, the emergency codes (31603 or 31605) may be more appropriate.
Indication — clear documentation of the underlying clinical reason for the tracheostomy, from which the correct ICD-10-CM diagnosis code is derived.
Anatomic level — documentation of which tracheal ring level the stoma was created at (e.g., between 2nd and 3rd rings). This supports appropriate coding and also has quality/safety documentation value.
Thyroid isthmus management — if the isthmus was divided, ligated, or retracted, this should be documented. Division of the isthmus does not support a separate thyroid code — it is incidental to 31600.
Concurrent laryngoscopy — if a laryngoscope was used to facilitate placement, it should be documented as an adjunct to the tracheostomy, not as a separate diagnostic or therapeutic procedure, to avoid inappropriate dual billing.
Tracheostomy tube type and size — confirms tube placement and supports accurate supply coding if applicable.
Bronchoscopic guidance (for PDT) — if bronchoscopy was used to guide needle placement and dilator passage during PDT, its use should be explicitly documented and the PCS approach character should be 4 (Percutaneous Endoscopic) rather than 3, supporting a higher-value OR-designated PCS code and potentially affecting DRG assignment.

Coding Examples

Example 1 — Standard Planned Open Tracheostomy in Ventilated Patient An adult ICU patient has been on mechanical ventilation for 12 days following acute hypoxic respiratory failure from bilateral pneumonia. The patient is not showing signs of imminent wean and continues to require full ventilatory support. The otolaryngologist performs an elective open tracheostomy. A horizontal incision is made, strap muscles are separated, the thyroid isthmus is divided and ligated, and the trachea is entered between the 2nd and 3rd rings. A cuffed tracheostomy tube is placed. The tube change is first performed on day 7.

Physician CPT: 31600 ICD-10-CM Diagnoses: J96.01 (Acute respiratory failure with hypoxia), J18.9 (Pneumonia, unspecified organism) ICD-10-PCS (inpatient): 0B110F4 (Bypass Trachea to Cutaneous with Tracheostomy Device, Open Approach), 5A1955Z (Respiratory Ventilation, Greater than 96 Consecutive Hours) DRG Consideration: If ventilation exceeded 96 hours and the principal diagnosis is not a face/mouth/neck condition → case groups to DRG 003 or DRG 004 depending on presence of other major O.R. procedures. This is an extremely high-weight DRG.

Example 2 — Planned Percutaneous Dilational Tracheostomy with Bronchoscopic Guidance An ICU physician performs a percutaneous dilational tracheostomy at the bedside in an intubated 62-year-old with COPD exacerbation and respiratory failure. Flexible bronchoscopy is performed throughout to confirm proper needle placement and dilator trajectory. A blue rhino single-step dilator is used. A size 8.0 cuffed tracheostomy tube is placed. The patient has been on mechanical ventilation for 5 days at the time of the procedure.

Physician CPT: 31601 (percutaneous dilational tracheostomy, any age — NOT 31600) ICD-10-PCS (inpatient): 0B114F4 (Bypass Trachea to Cutaneous with Tracheostomy Device, Percutaneous Endoscopic Approach) — endoscopic because bronchoscopic guidance was used Critical Inpatient Coding Note: 0B114F4 (not 0B113F4) is the correct code when bronchoscopic guidance was documented. 0B114F4 is OR-designated. If the patient’s ventilation reaches 96+ hours, the case may qualify for DRG 003/004.

Example 3 — Open Tracheostomy for Laryngeal Cancer — Separate from Concurrent Neck Dissection A patient with T3 glottic laryngeal cancer undergoes total laryngectomy (31360), bilateral selective neck dissection (38724 billed twice with bilateral modifier consideration), and at the conclusion, a formal tracheostomy tube is placed through the end-tracheal stoma created as part of the laryngectomy.

Correct Coding: 31360 only (laryngectomy). The tracheostomy created as part of the laryngectomy is integral to that procedure. CPT 31600 is NOT separately reportable because the tracheostomy stoma was created as a component of — not in addition to — the laryngectomy. Note: The permanent tracheostoma created at the conclusion of total laryngectomy is coded within the laryngectomy CPT code itself. This is one of the most common overcoding errors in head and neck surgery — billing 31600 in addition to a laryngectomy code.

Example 4 — Tracheostomy with Concurrent Unrelated Abdominal Procedure A patient with acute respiratory failure from ARDS following a major abdominal surgery requires a tracheostomy performed 6 days into the hospitalization. The abdominal surgery was performed at the same admission and has its own 90-day global period. The tracheostomy is performed by a different surgeon (pulmonologist) than the one who performed the abdominal surgery.

Tracheostomy Physician CPT: 31600 DRG: Will be based on the combined procedure codes from the full stay. If ventilation >96h is documented → DRG 003 or 004 likely applies. Global Period Note: Because a different physician is performing the tracheostomy than the one who performed the abdominal surgery, there is no global period conflict. The tracheostomy surgeon bills 31600 without a modifier. If the same surgeon performed both, Modifier 79 (unrelated procedure during postoperative period) would be required.

Example 5 — Post-Tracheostomy Tube Change During Fistula Formation Window An ENT surgeon performs an open tracheostomy on hospital day 3. On hospital day 7, the tracheostomy tube is inadvertently dislodged and a tube exchange must be performed before the fistula tract has matured (confirmed by the surgeon’s documentation that the tract is not yet epithelialized).

Code for Tube Change: 31502 (Tracheotomy tube change prior to establishment of fistula tract) Note: This is the only circumstance in which a separate tracheostomy tube change procedure code exists and is reportable. Do NOT report 31502 for tube changes after the fistula is established (typically after day 7-10). After fistula formation, tube changes are routine services included in any related E/M visit.

Example 6 — Inpatient Coder Scenario — DRG 003 vs. DRG 004 Determination A 70-year-old patient is admitted with septic shock due to aspiration pneumonia. The patient is intubated in the ED and placed on mechanical ventilation. On hospital day 11, an open tracheostomy is performed. On hospital day 14, the patient undergoes exploratory laparotomy (0DTE0ZZ — Resection of Large Intestine, Open Approach) for a concurrent bowel perforation.

ICD-10-PCS Codes: 0B110F4 (tracheostomy, open), 5A1955Z (mechanical ventilation >96h), 0DTE0ZZ (bowel resection, major O.R. procedure) DRG Assignment: DRG 003 — ECMO or Tracheostomy with MV >96 Hours with Major O.R. Procedure. The bowel resection qualifies as a “major O.R. procedure” pushing the case to DRG 003 rather than DRG 004. DRG 003 carries a significantly higher relative weight than DRG 004. Inpatient Coding Takeaway: The presence of ANY major O.R. procedure in a tracheostomy + MV>96h case can shift the DRG from 004 to 003, with meaningful reimbursement impact. All procedures should be coded accurately and completely.

Coding Pitfalls and Common Errors

Using 31600 for percutaneous dilational tracheostomy (PDT): The single most common tracheostomy coding error. PDT must be reported as 31601 regardless of patient age. The only exception is a child younger than 2 years who undergoes an open tracheostomy — that is also 31601 due to age-based complexity.
Separately billing 31600 with laryngectomy: The tracheostomy created at the time of total laryngectomy is integral to the laryngectomy procedure and is included in 31360 or 31365. Billing 31600 in addition to a laryngectomy code is an overcoding error and a compliance risk.
Separately billing 31600 with thyroidectomy/parathyroidectomy at the same neck site: The “separate procedure” designation in 31600 prohibits separate billing when the tracheostomy is a routine component of the larger same-site neck procedure. Only if the tracheostomy was performed for an independent indication unrelated to the thyroid/parathyroid surgery — and at a distinct anatomic approach — may Modifier 59 support separate billing.
Missing 5A1955Z (Mechanical Ventilation >96 Hours) on inpatient claims: This PCS code is among the most financially significant non-OR procedure codes in the entire ICD-10-PCS system. When a tracheostomy patient has been on mechanical ventilation for more than 96 consecutive hours and this code is not captured, the case cannot group to DRG 003 or 004, potentially costing the facility tens of thousands of dollars in lost reimbursement.
Using 0B113F4 instead of 0B114F4 for bronchoscopy-guided PDT: When bronchoscopic guidance is documented during PDT, the approach character in PCS is 4 (Percutaneous Endoscopic) — code 0B114F4 — which is OR-designated. Using 0B113F4 (Percutaneous, no endoscope) when bronchoscopic guidance was clearly performed results in a non-OR code that does not support Pre-MDC DRG grouping.
Billing 31502 for routine tube changes after fistula formation: CPT 31502 is only applicable before the fistula tract has matured (first 7-10 days). Billing 31502 for routine tube changes at the weekly wound care visit weeks or months later is incorrect and will typically be denied or flagged in an audit.
Not billing E/M visits post-tracheostomy under Medicare: Many surgeons and practice managers incorrectly assume a global period applies to 31600 under Medicare and forfeit post-operative E/M billing. Under Medicare’s 0-day global, every visit after the operative day is separately billable. Over the course of a complex ICU patient’s hospital stay, this can represent significant recoverable revenue.
Assigning 31600 as the inpatient procedure code on a UB-04: ICD-10-PCS codes, not CPT codes, are used for inpatient facility claims. Assigning CPT 31600 as a procedure on an inpatient claim is a billing error.

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