How To Use CPT Code 31360

CPT 31360 describes the excision of the larynx without radical neck dissection. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31360?

CPT 31360 involves the removal of the larynx (voice box) without radical neck dissection. This procedure is performed to address certain medical conditions or diseases affecting the larynx. It is important to note that this code specifically refers to the excision of the larynx without the removal of additional tissues or lymph nodes in the neck.

2. Official Description

The official description of CPT code 31360 is: ‘Laryngectomy; total, without radical neck dissection.’

3. Procedure

1. Before the main surgery, the patient is appropriately prepped and anesthetized.
2. The provider performs a separate incision for tracheostomy, allowing the patient to breathe during the procedure.
3. An incision is made into the neck to access and remove the larynx.
4. The muscles in front of the patient’s neck are divided.
5. Part or all of the hyoid bone is removed.
6. The provider identifies the thyroid isthmus, which is detached from the anterior part of the trachea (windpipe).
7. The diseased tissue, including the entire larynx, is excised.
8. The wound is closed in layers.
9. This procedure does not involve radical neck dissection.

4. Qualifying circumstances

CPT 31360 is performed when the removal of the larynx is necessary without the need for additional tissue or lymph node removal in the neck. It is important to note that radical neck dissection is not performed during this procedure. The provider may decide to perform a tracheostomy to ensure the patient’s ability to breathe during the surgery.

5. When to use CPT code 31360

CPT code 31360 should be used when a total laryngectomy is performed without radical neck dissection. It is important to accurately document the procedure and ensure that it aligns with the official description of CPT 31360.

6. Documentation requirements

To support a claim for CPT 31360, the following documentation is required:

• Clear indication of the need for laryngectomy without radical neck dissection
• Description of the procedure performed, including any additional steps such as tracheostomy
• Date of the surgery
• Details of the incisions made and tissues removed
• Confirmation that radical neck dissection was not performed
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 31360, ensure that the procedure performed aligns with the official description and documentation requirements. It is important to accurately report the procedure without any additional services or procedures that are not included in CPT 31360. Be aware of any specific guidelines or requirements from insurance providers or payers.

8. Historical information

CPT 31360 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates or changes since its addition. It is important to stay updated with any future changes or revisions to ensure accurate reporting.

9. Examples

1. A patient undergoes a total laryngectomy without radical neck dissection to address laryngeal cancer.
2. A provider performs a laryngectomy without radical neck dissection on a patient with severe laryngeal trauma.
3. Another example of CPT 31360 without using the code or official description.
4. Provide seven more examples of cases where CPT 31360 is used. Ensure that each example is unique and does not include the code or official description.