How To Use CPT Code 31540

CPT 31540 describes the operative procedure of laryngoscopy with excision of tumor and/or stripping of vocal cords or epiglottis. This article will cover the description, official definition, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31540?

CPT 31540 is used to describe a surgical procedure involving the use of a laryngoscope to directly visualize the larynx and adjacent structures. During this procedure, the provider may remove abnormal masses of tissue from the vocal cords or epiglottis, known as stripping, or excise tumors.

2. Official Description

The official description of CPT code 31540 is: ‘Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider inserts a laryngoscope into the throat to directly view the laryngeal and hypopharyngeal structures.
3. The provider identifies any tumors or abnormal masses in the vocal cords or epiglottis.
4. If necessary, the provider may use forceps to strip or remove the outer layers of the vocal cords or epiglottis.
5. The provider may also use a scalpel, laser, or other tools to excise tumors from the larynx.

4. Qualifying circumstances

CPT 31540 is performed when there is a need to visualize and treat abnormalities in the larynx, vocal cords, or epiglottis. This procedure is typically performed by a qualified healthcare professional who has the necessary training and expertise in laryngoscopy and surgical techniques. The patient must meet the criteria for the procedure, such as having a tumor or abnormal mass that requires excision or stripping.

5. When to use CPT code 31540

CPT code 31540 should be used when a provider performs a direct laryngoscopy with excision of tumor and/or stripping of vocal cords or epiglottis. This code is appropriate when the procedure is performed as a standalone operation or as part of a larger surgical intervention involving the larynx.

6. Documentation requirements

To support a claim for CPT 31540, the provider must document the following information:

• Patient’s diagnosis and the need for laryngoscopy with excision or stripping
• Details of the procedure, including the use of a laryngoscope and any additional tools
• Date and duration of the procedure
• Specific findings during the procedure, such as the presence of tumors or abnormal masses
• Details of any excision or stripping performed
• Any complications or unexpected events during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 31540, ensure that the procedure meets the criteria outlined in the official description. It is important to accurately document the details of the procedure and any additional services provided. CPT code 31540 should not be reported with other codes unless there are separate and distinct procedures performed. It is also important to follow any specific guidelines or requirements from the payer when submitting claims for this procedure.

8. Historical information

CPT 31540 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 surgeon performs laryngoscopy with excision of a vocal cord tumor in a patient with suspected laryngeal cancer.
2. An otolaryngologist performs laryngoscopy with stripping of the epiglottis in a patient with chronic epiglottitis.
3. A head and neck surgeon performs laryngoscopy with excision of a vocal cord polyp in a patient with hoarseness.
4. An ENT specialist performs laryngoscopy with excision of a laryngeal papilloma in a pediatric patient.
5. A laryngologist performs laryngoscopy with excision of a vocal cord cyst in a professional singer.
6. A surgeon performs laryngoscopy with excision of a vocal cord granuloma in a patient with vocal cord dysfunction.
7. An otolaryngologist performs laryngoscopy with stripping of the vocal cords in a patient with chronic laryngitis.
8. A head and neck surgeon performs laryngoscopy with excision of a vocal cord polyp in a patient with dysphonia.
9. An ENT specialist performs laryngoscopy with excision of a laryngeal papilloma in a patient with recurrent respiratory papillomatosis.
10. A laryngologist performs laryngoscopy with excision of a vocal cord cyst in a patient with voice changes.