How To Use CPT Code 31536

CPT 31536 describes the direct operative laryngoscopy procedure with biopsy, using an operating microscope or telescope. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31536?

CPT 31536 is used to describe a specific procedure called direct operative laryngoscopy with biopsy. During this procedure, a healthcare provider uses a laryngoscope to directly examine the larynx, or voice box, for any abnormalities. If any abnormal or diseased tissues are found, a sample is surgically removed for further study, which is known as a biopsy. The provider may use an operating microscope or telescope to ensure proper visualization of difficult areas.

2. Official Description

The official description of CPT code 31536 is: ‘Laryngoscopy, direct, operative, with biopsy; with operating microscope or telescope.’

3. Procedure

1. After appropriate preparation and anesthesia, the healthcare provider inserts a laryngoscope into the throat to directly view the laryngeal and hypopharyngeal structures.
2. The provider identifies any lesions or target tissues that require biopsy.
3. Using an instrument such as micro-scissors, the provider removes a sample of the abnormal or diseased tissues under the guidance of an operating microscope or telescope.
4. The provider ensures bleeding control and removes the laryngoscope.

4. Qualifying circumstances

CPT 31536 is performed when a patient requires direct operative laryngoscopy with biopsy. This procedure is typically done to investigate and diagnose abnormalities or diseases in the larynx. The patient may have symptoms such as hoarseness, difficulty swallowing, or persistent cough. The healthcare provider must use an operating microscope or telescope during the procedure to visualize difficult areas.

5. When to use CPT code 31536

CPT code 31536 should be used when a healthcare provider performs a direct operative laryngoscopy with biopsy using an operating microscope or telescope. This code accurately represents the specific procedure being performed. It should not be used for other types of laryngoscopy procedures or biopsies.

6. Documentation requirements

To support a claim for CPT 31536, the healthcare provider must document the following information:

• Patient’s symptoms or indications for the procedure
• Details of the direct operative laryngoscopy procedure, including the use of an operating microscope or telescope
• Description of the biopsy performed
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 31536, ensure that the procedure meets the specific criteria outlined in the code description. The use of an operating microscope or telescope is essential for accurate reporting. It is important to note that code 69990 should not be reported in addition to code 31536. Additional tips and guidelines for reporting CPT 31536 can be found in the official coding resources.

8. Historical information

CPT 31536 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 operative laryngoscopy with biopsy using an operating microscope to investigate a patient’s persistent hoarseness.
2. During a direct operative laryngoscopy with biopsy, a provider uses a telescope to visualize difficult areas and removes a sample of abnormal tissues from a patient’s larynx for further study.
3. A patient with difficulty swallowing undergoes a direct operative laryngoscopy with biopsy, during which the provider uses an operating microscope to guide the removal of a tissue sample.
4. A healthcare provider performs a direct operative laryngoscopy with biopsy using an operating microscope to investigate a persistent cough in a patient.
5. During a direct operative laryngoscopy with biopsy, a provider uses a telescope to visualize difficult areas and removes a sample of abnormal tissues from a patient’s hypopharynx for further study.
6. A patient with voice changes undergoes a direct operative laryngoscopy with biopsy, during which the provider uses an operating microscope to guide the removal of a tissue sample from the larynx.
7. A healthcare provider performs a direct operative laryngoscopy with biopsy using an operating microscope to investigate a patient’s recurrent throat pain.
8. During a direct operative laryngoscopy with biopsy, a provider uses a telescope to visualize difficult areas and removes a sample of abnormal tissues from a patient’s larynx for further study.
9. A patient with persistent cough undergoes a direct operative laryngoscopy with biopsy, during which the provider uses an operating microscope to guide the removal of a tissue sample.
10. A healthcare provider performs a direct operative laryngoscopy with biopsy using an operating microscope to investigate a patient’s difficulty swallowing.