How To Use CPT Code 31395

CPT 31395 describes the procedure of pharyngolaryngectomy with radical neck dissection and reconstruction. 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 31395?

CPT 31395 represents a surgical procedure called pharyngolaryngectomy with radical neck dissection and reconstruction. This code is used when a provider removes the pharynx and larynx, commonly performed in patients experiencing difficulty swallowing. The procedure also involves reconstruction to restore the functionality of the pharynx and larynx.

2. Official Description

The official description of CPT code 31395 is: ‘Pharyngolaryngectomy, with radical neck dissection; with reconstruction.’

3. Procedure

1. The provider begins by making a separate incision for tracheostomy to ensure the patient can breathe during the surgery.
2. A horizontal neck incision is made at the level of the thyroid cartilage to expose the larynx.
3. The provider raises flaps from under the platysmal muscles, extending from the collarbone to the jaw, to further expose the larynx.
4. The hyoid bone, which provides structural support to the tongue, is partially or completely removed.
5. Lymph nodes are excised as part of the radical neck dissection.
6. The provider continues the dissection by removing muscles in the front of the neck, the internal jugular vein, and the submandibular gland.
7. The larynx is then removed, and if necessary, an incision may be made on the esophagus to access the pharynx.
8. During the same procedure, the provider performs reconstruction by creating flaps from the pectoralis major muscle or the latissimus dorsi muscle.
9. The size of the area to be covered with the flap is measured and marked, and the flap is transferred to the neck to reconstruct the pharynx and larynx.
10. The area is closed with sutures, including the overlying subcutaneous tissue and skin.

4. Qualifying circumstances

CPT 31395 is performed on patients who have difficulty swallowing and require the removal of the pharynx and larynx. The procedure also involves radical neck dissection and reconstruction. It is important to note that this procedure should only be performed by a qualified provider with the necessary expertise.

5. When to use CPT code 31395

CPT code 31395 should be used when a provider performs pharyngolaryngectomy with radical neck dissection and reconstruction. It is important to ensure that the procedure meets the specific criteria outlined in the code description. This code should not be used for any other procedures or circumstances.

6. Documentation requirements

To support a claim for CPT 31395, the provider must document the following information:

• Indication for the procedure and the patient’s difficulty swallowing
• Details of the surgical technique used, including the specific steps performed
• Documentation of the reconstruction procedure, including the type of flaps used
• Date of the procedure and the duration of the surgery
• Any complications or unexpected findings during the surgery
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 31395, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should only be reported by a qualified provider with the necessary expertise. It is also important to follow any additional guidelines provided by payers or regulatory bodies.

8. Historical information

CPT code 31395 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient with advanced throat cancer undergoes pharyngolaryngectomy with radical neck dissection and reconstruction to remove the affected tissues and restore swallowing function.
2. A provider performs pharyngolaryngectomy with radical neck dissection and reconstruction on a patient with a large tumor in the larynx, aiming to remove the tumor and reconstruct the affected structures.
3. Pharyngolaryngectomy with radical neck dissection and reconstruction is performed on a patient with recurrent laryngeal cancer to remove the cancerous tissues and reconstruct the pharynx and larynx.
4. A patient with a history of radiation therapy for throat cancer undergoes pharyngolaryngectomy with radical neck dissection and reconstruction to address complications and improve swallowing function.
5. A provider performs pharyngolaryngectomy with radical neck dissection and reconstruction on a patient with a rare tumor in the pharynx, aiming to remove the tumor and reconstruct the affected structures.
6. Pharyngolaryngectomy with radical neck dissection and reconstruction is performed on a patient with a large tumor in the larynx, aiming to remove the tumor and reconstruct the affected structures.
7. A patient with advanced throat cancer undergoes pharyngolaryngectomy with radical neck dissection and reconstruction to remove the affected tissues and restore swallowing function.
8. A provider performs pharyngolaryngectomy with radical neck dissection and reconstruction on a patient with a large tumor in the larynx, aiming to remove the tumor and reconstruct the affected structures.
9. Pharyngolaryngectomy with radical neck dissection and reconstruction is performed on a patient with recurrent laryngeal cancer to remove the cancerous tissues and reconstruct the pharynx and larynx.