How To Use CPT Code 31365

CPT 31365 describes a surgical procedure that involves the removal of the larynx (voice box) with radical neck dissection. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31365?

CPT 31365 is used to describe a surgical procedure in which the provider removes the larynx (voice box) with radical neck dissection. This procedure is performed to treat certain conditions or diseases that affect the larynx and surrounding tissues. It involves the removal of lymph nodes and other adjacent tissues in addition to the larynx.

2. Official Description

The official description of CPT code 31365 is: ‘Laryngectomy; total, with radical neck dissection.’

3. Procedure

1. The provider begins by preparing and anesthetizing the patient.
2. A separate incision is made for tracheostomy to allow the patient to breathe during the surgery.
3. An incision is made into the neck to access the larynx.
4. The provider divides the muscles in the front of the patient’s neck.
5. Part or all of the hyoid bone is removed.
6. The provider identifies the thyroid isthmus, which is the band of tissue joining the lobes of the thyroid gland.
7. The thyroid isthmus is detached from the anterior part of the trachea (windpipe).
8. The provider performs extensive excision of the diseased tissue, including the entire larynx and surrounding lymph nodes, muscles, glands, and veins as necessary.
9. The wound is closed in layers.
10. This procedure is performed with radical neck dissection, which involves the removal of a mass or tumor from the neck along with additional normal tissue, lymph nodes, and other structures.

4. Qualifying circumstances

CPT 31365 is performed on patients who require the removal of the larynx (voice box) due to certain conditions or diseases. This procedure is typically performed when other treatment options have been exhausted or are not suitable for the patient. It may be necessary for patients with cancerous tumors or other conditions that affect the larynx and surrounding tissues. The procedure is performed by a qualified healthcare provider who has the necessary expertise and training in laryngectomy and radical neck dissection.

5. When to use CPT code 31365

CPT code 31365 should be used when a total laryngectomy is performed along with radical neck dissection. This code is appropriate when the provider removes the entire larynx and performs extensive excision of surrounding tissues, lymph nodes, muscles, glands, and veins. It is important to accurately document the details of the procedure to support the use of CPT code 31365.

6. Documentation requirements

To support a claim for CPT code 31365, the following documentation is required:

• Patient’s diagnosis and the need for laryngectomy with radical neck dissection
• Details of the procedure, including the incisions made, tissues removed, and structures dissected
• Extent of the excision performed, including the larynx, lymph nodes, muscles, glands, and veins
• Any additional procedures performed during the surgery
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 31365, ensure that the procedure performed meets the criteria for a total laryngectomy with radical neck dissection. It is important to accurately document the details of the procedure to support the use of this code. CPT code 31365 should not be reported with other codes that describe similar procedures or components of the procedure. It is important to review the documentation and guidelines provided by the payer to ensure accurate and appropriate billing.

8. Historical information

CPT code 31365 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient with advanced laryngeal cancer undergoes a total laryngectomy with radical neck dissection to remove the tumor and affected lymph nodes.
2. A patient with a recurrent tumor in the larynx undergoes a total laryngectomy with radical neck dissection to ensure complete removal of the cancerous tissue.
3. A patient with a large tumor in the larynx undergoes a total laryngectomy with radical neck dissection to remove the tumor and surrounding lymph nodes.
4. A patient with a history of laryngeal cancer undergoes a total laryngectomy with radical neck dissection as a preventive measure to remove any remaining cancer cells.
5. A patient with a rare tumor in the larynx undergoes a total laryngectomy with radical neck dissection to remove the tumor and affected lymph nodes.
6. A patient with a recurrent infection in the larynx undergoes a total laryngectomy with radical neck dissection to remove the infected tissue and prevent further complications.
7. A patient with a large tumor in the larynx undergoes a total laryngectomy with radical neck dissection to remove the tumor and ensure complete removal of any affected lymph nodes.
8. A patient with a history of radiation therapy for laryngeal cancer undergoes a total laryngectomy with radical neck dissection to remove any remaining cancer cells and prevent recurrence.
9. A patient with a rare tumor in the larynx undergoes a total laryngectomy with radical neck dissection to remove the tumor and affected lymph nodes.