How To Use CPT Code 31526

CPT 31526 describes the diagnostic procedure of direct laryngoscopy, with or without tracheoscopy, using an operating microscope or telescope. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31526?

CPT 31526 can be used to describe the diagnostic procedure of direct laryngoscopy, with or without tracheoscopy, using an operating microscope or telescope. This code is used when a healthcare provider uses a laryngoscope to directly visualize the larynx and adjacent structures to detect any abnormalities. The provider may also perform tracheoscopy to visualize the interior of the trachea if necessary.

2. Official Description

The official description of CPT code 31526 is: ‘Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The healthcare provider inserts a laryngoscope into the throat to directly view the laryngeal and hypopharyngeal structures.
3. If necessary, the provider may use an operating microscope or telescope to properly visualize difficult areas, hidden pathology, and anatomy.
4. The provider may also perform tracheoscopy to visualize the interior of the trachea, if needed.

4. Qualifying circumstances

CPT 31526 is performed when a healthcare provider needs to visually examine the larynx and adjacent structures for diagnostic purposes. This procedure is typically done under general anesthesia or conscious sedation. It is important to note that CPT code 31526 should not be reported in conjunction with code 69990.

5. When to use CPT code 31526

CPT code 31526 should be used when a healthcare provider performs a direct laryngoscopy, with or without tracheoscopy, for diagnostic purposes using an operating microscope or telescope. This code should not be used for other types of laryngoscopy procedures or when the procedure is performed for therapeutic purposes.

6. Documentation requirements

To support a claim for CPT 31526, the healthcare provider must document the following information:

• Reason for the procedure and the need for diagnostic evaluation
• Details of the procedure performed, including whether tracheoscopy was performed
• Date and time of the procedure
• Findings and any abnormalities detected
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 31526, ensure that the procedure meets the criteria described in the official description. It is important to note that CPT code 31526 should not be reported in conjunction with code 69990. Review the documentation requirements and ensure that all necessary information is included in the medical record to support the claim.

8. Historical information

CPT 31526 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A healthcare provider performs a direct laryngoscopy with an operating microscope to evaluate a patient with hoarseness and detects a vocal cord polyp.
2. During a diagnostic procedure, a provider uses a laryngoscope and an operating telescope to visualize the larynx and hypopharyngeal structures in a patient with difficulty swallowing.
3. A healthcare provider performs a direct laryngoscopy with tracheoscopy using an operating microscope to evaluate a patient with suspected laryngeal cancer.
4. Using an operating telescope, a provider performs a direct laryngoscopy to examine the larynx and hypopharynx in a patient with chronic cough.
5. A healthcare provider performs a direct laryngoscopy with an operating microscope to assess a patient with persistent voice changes and identifies a vocal cord lesion.
6. During a diagnostic procedure, a provider uses a laryngoscope and an operating telescope to visualize the larynx and hypopharyngeal structures in a patient with recurrent throat infections.
7. A healthcare provider performs a direct laryngoscopy with tracheoscopy using an operating microscope to evaluate a patient with suspected tracheal stenosis.
8. Using an operating telescope, a provider performs a direct laryngoscopy to examine the larynx and hypopharynx in a patient with suspected vocal cord paralysis.
9. A healthcare provider performs a direct laryngoscopy with an operating microscope to assess a patient with persistent throat pain and identifies an abnormality in the larynx.
10. During a diagnostic procedure, a provider uses a laryngoscope and an operating telescope to visualize the larynx and hypopharyngeal structures in a patient with suspected laryngeal trauma.