Find comprehensive information on tracheomalacia diagnosis, including clinical documentation requirements, ICD-10-CM coding (J38.5), and medical billing guidelines. Learn about symptoms, diagnostic procedures like bronchoscopy and imaging, and treatment options for tracheomalacia in infants, children, and adults. Explore resources for healthcare professionals on accurately documenting and coding this condition for optimal reimbursement and patient care. This resource covers congenital tracheomalacia, acquired tracheomalacia, and related breathing difficulties.
Also known as
Tracheomalacia congenital
Congenital softening of the tracheal cartilage.
Respiratory disorders NEC
Other specified respiratory conditions not elsewhere classified.
Other congenital malformations of trachea
Includes other congenital abnormalities affecting the trachea.
Acquired tracheal stenosis
Narrowing of the trachea acquired after birth, can be related.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the tracheomalacia congenital?
Yes
Any other laryngotracheal anomalies?
No
Is there a specified cause?
When to use each related code
| Description |
|---|
| Soft, floppy trachea |
| Trachea narrowing |
| Bronchomalacia |
Coding unspecified tracheomalacia (J38.5) when documentation supports a more specific type (e.g., congenital, acquired) leads to inaccurate data and potential DRG misrepresentation.
Overlooking comorbidities (e.g., respiratory infections, prematurity) associated with tracheomalacia impacts severity and resource utilization, affecting reimbursement.
Insufficient clinical evidence to support the diagnosis of tracheomalacia can lead to claim denials and compliance issues during audits.
Patient presents with symptoms suggestive of tracheomalacia. Key findings include expiratory stridor, wheezing, barking cough, and recurrent respiratory infections. Differential diagnosis considered laryngomalacia, bronchomalacia, asthma, and foreign body aspiration. Physical exam revealed normal vocal cord function, ruling out laryngomalacia. Flexible bronchoscopy demonstrated dynamic collapse of the tracheal lumen during exhalation, confirming the diagnosis of tracheomalacia. Severity assessed as [mild, moderate, or severe] based on the degree of tracheal collapse observed. Treatment plan focuses on supportive care including airway clearance techniques and pulmonary rehabilitation. Patient education provided on recognizing signs of respiratory distress and appropriate management strategies. Follow-up scheduled to monitor respiratory status and adjust treatment as needed. ICD-10 code J38.5 assigned. Medical necessity for bronchoscopy documented.