temp trach

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
I admit that procedure coding is my downfall so here I go. I am reviewing a chart that is currently coded with a temp trach. This is a patient who presented to an OP clinic with dysphagia, SOB, wightloss and swallowing trouble. He presented for same day surgery the following day for trach/PEG and biopsy for suspected cancer (tongue cancer). The trach portion of the procedure reads as follows:


"transverse incision was made in the skin withelevation of the skin above and below, followed by midline separation going through multiple layers to get down to the anterior rings of the trachea. Small amounts of bleeding were found and controlled with cautery. We were able to get down to ring #2. After cleaning this off with no obvious bleeding at this time, a 15 blade was used to incise above and below this ring

and the anterior portion of this was cut and removed. This was dilated and then we placed a #8 Shiley trach tube through this area easily with good control of his airway. This was sewn into place. A trach sponge was placed with no significant bleeding from this portion of the case. The trach was sewn into place."



Would you code this as a permanent or temp trach?



Thanks!



Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • martin.conroymartin.conroy
    edited April 2016
    Our physicians have told us as a general rule when it is scheduled and/or in the OR it is considered permanent. If it is emergent and/or bedside it is usually consider temp. This is the guidelines our coders use. We do not query for trachs perm. Vs. temp.

    Marty
    Temple Health

  • angelisa.romanelloangelisa.romanello
    edited April 2016
    Great way to differentiate.
    Thank you Marty

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