How To Use CPT Code 31528

CPT 31528 describes the initial dilation of the larynx using direct laryngoscopy, with or without tracheoscopy. 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 31528?

CPT 31528 can be used to describe the initial dilation of the larynx using direct laryngoscopy, with or without tracheoscopy. This code is used when a healthcare provider inserts a laryngoscope into the throat to directly view the larynx and adjacent structures. The provider may also use a dilator to widen any narrowed areas in the larynx or trachea. This code represents the initial dilation procedure.

2. Official Description

The official description of CPT code 31528 is: ‘Laryngoscopy direct, with or without tracheoscopy; with dilation, initial.’

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. The provider inserts a laryngoscope into the throat to directly view the larynx and hypopharyngeal structures.
3. If necessary, the provider uses a dilator to widen any narrowed areas in the larynx or trachea.
4. The provider removes the dilator and the laryngoscope.
5. If needed, the provider may perform tracheoscopy to visualize the interior of the trachea.

4. Qualifying circumstances

CPT 31528 is performed on patients who have a narrowed larynx or trachea that requires dilation. The procedure is typically done under general anesthesia or conscious sedation. The healthcare provider uses a laryngoscope to directly view the larynx and may insert a dilator to widen any narrowed areas. Tracheoscopy may also be performed to visualize the trachea if necessary.

5. When to use CPT code 31528

CPT code 31528 should be used when the healthcare provider performs the initial dilation of the larynx using direct laryngoscopy, with or without tracheoscopy. This code represents the first dilation procedure and should not be used for subsequent dilations.

6. Documentation requirements

To support a claim for CPT 31528, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for laryngeal dilation
• Details of the procedure, including the use of a laryngoscope and any dilators
• Date of the procedure
• Any additional procedures performed, such as tracheoscopy
• Any complications or adverse events
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 31528, ensure that the procedure meets the criteria for laryngeal dilation using direct laryngoscopy, with or without tracheoscopy. It is important to document the use of a laryngoscope and any dilators used during the procedure. CPT code 31528 should not be reported with subsequent dilation codes. It is also important to follow any specific guidelines provided by the payer regarding documentation and billing for this procedure.

8. Historical information

CPT 31528 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2002, with the addition of the term ‘initial dilation’ to the code description.

9. Examples

1. A patient with a narrowed larynx undergoes direct laryngoscopy with dilation to widen the airway.
2. A healthcare provider performs laryngoscopy with dilation on a patient with tracheal stenosis.
3. A laryngoscopy with dilation is performed on a patient with a laryngeal tumor to improve breathing.
4. A child with a congenital laryngeal abnormality undergoes direct laryngoscopy with dilation to correct the issue.
5. A patient with a history of laryngeal trauma undergoes laryngoscopy with dilation to improve vocal cord function.
6. A healthcare provider performs laryngoscopy with dilation on a patient with a narrowed trachea due to scarring.
7. A laryngoscopy with dilation is performed on a patient with a laryngeal stricture to improve swallowing.
8. A patient with a history of radiation therapy undergoes direct laryngoscopy with dilation to address radiation-induced laryngeal stenosis.
9. A healthcare provider performs laryngoscopy with dilation on a patient with a laryngeal web to improve vocal cord function.
10. A patient with a narrowed larynx due to inflammation undergoes direct laryngoscopy with dilation to alleviate symptoms.