How To Use CPT Code 31368

CPT 31368 describes a surgical procedure known as subtotal supraglottic laryngectomy with radical neck dissection. This article will provide an overview of the code, including its official description, the procedure involved, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes.

1. What is CPT Code 31368?

CPT 31368 is used to describe a surgical procedure in which the upper part of the larynx, specifically the supraglottis region, is removed along with a radical neck dissection. This procedure is performed by a healthcare provider to treat certain conditions affecting the larynx and surrounding tissues.

2. Official Description

The official description of CPT code 31368 is: ‘Laryngectomy; subtotal supraglottic, with radical neck dissection.’

3. Procedure

1. The healthcare provider begins by preparing and anesthetizing the patient.
2. A separate incision is made for tracheostomy to ensure the patient can breathe during the surgery.
3. A neck incision is then made to access the supraglottis region, which is the area above the vocal cords.
4. The provider carefully preserves the muscles above the thyroid gland and the hypoglossal and laryngeal nerves.
5. The thyroid cartilages are dissected to reach the diseased tissue.
6. The provider removes the diseased tissues, including the epiglottis, false vocal cords, and upper half of the thyroid cartilage.
7. In addition to the laryngeal structures, the procedure involves the removal of the sternocleidomastoid muscle, internal jugular vein, submandibular salivary gland, and lymph nodes of the neck.
8. The wound is closed in layers to complete the procedure.

4. Qualifying circumstances

CPT 31368 is performed on patients who require the removal of the upper part of the larynx and radical neck dissection. This procedure is typically indicated for conditions such as supraglottic cancer, which affects the upper part of the larynx. The procedure is performed by a qualified healthcare provider who has the necessary expertise in performing laryngeal surgeries.

5. When to use CPT code 31368

CPT code 31368 should be used when a subtotal supraglottic laryngectomy with radical neck dissection is performed. It is important to accurately document the specific procedure performed to ensure proper coding and billing.

6. Documentation requirements

To support a claim for CPT 31368, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for subtotal supraglottic laryngectomy with radical neck dissection
• Details of the procedure performed, including the specific structures removed
• Date of the surgery
• Any additional relevant information, such as complications or additional procedures performed
• Signature of the healthcare provider performing the surgery

7. Billing guidelines

When billing for CPT 31368, it is important to ensure that the procedure performed matches the description of the code. The healthcare provider should also follow any specific billing guidelines provided by the payer. It is important to accurately document the procedure and any additional services provided during the surgery.

8. Historical information

CPT code 31368 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 supraglottic cancer undergoes subtotal supraglottic laryngectomy with radical neck dissection to remove the diseased tissues and lymph nodes.
2. A healthcare provider performs subtotal supraglottic laryngectomy with radical neck dissection on a patient with advanced laryngeal cancer.
3. During the surgery, the provider removes the upper part of the larynx and surrounding tissues, including the epiglottis and false vocal cords.
4. A patient with recurrent supraglottic cancer undergoes subtotal supraglottic laryngectomy with radical neck dissection to remove the diseased tissues and lymph nodes.
5. The procedure is performed by a qualified healthcare provider who specializes in laryngeal surgeries.
6. After the surgery, the patient undergoes rehabilitation and speech therapy to regain their ability to speak.
7. A subtotal supraglottic laryngectomy with radical neck dissection is performed to remove a tumor in the supraglottis region and surrounding lymph nodes.
8. The procedure is performed under general anesthesia, and the patient is closely monitored throughout the surgery.
9. Following the surgery, the patient receives post-operative care and is monitored for any complications.
10. The healthcare provider ensures that the wound is properly closed to promote healing and minimize the risk of infection.