How To Use CPT Code 31545

CPT 31545 describes the operative procedure of laryngoscopy with submucosal removal of non-neoplastic lesions of the vocal cord, followed by reconstruction using local tissue flaps. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31545?

CPT 31545 can be used to describe a surgical procedure that involves the use of a laryngoscope and an operating microscope or telescope to directly visualize the larynx. During this procedure, the provider identifies and removes non-neoplastic lesions on the vocal cord. Additionally, the provider reconstructs the vocal cord using local tissue flaps.

2. Official Description

The official description of CPT code 31545 is: ‘Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s).’ This procedure involves the use of a laryngoscope and an operating microscope or telescope to directly visualize the larynx. The provider removes non-neoplastic lesions from the vocal cord and reconstructs it using local tissue flaps.

3. Procedure

1. The provider prepares the patient for the procedure, ensuring appropriate anesthesia and positioning.
2. Using a laryngoscope and an operating microscope or telescope, the provider inserts the instrument into the throat to directly visualize the larynx and adjacent structures.
3. A solution is injected beneath the vocal folds to mark the exact area of the lesions and protect the deeper vocal cords.
4. The provider identifies and isolates the non-neoplastic lesions on the vocal cord.
5. The provider removes the lesions by making incisions on the top layer and using dissection or suction.
6. Local tissue flaps are created using mucosa from a healthy site of the patient’s body.
7. The provider positions the tissue flaps over the vocal fold to reconstruct it.
8. The incision is closed using sutures.

4. Qualifying circumstances

CPT 31545 is performed on patients who have non-neoplastic lesions on their vocal cords that require surgical removal and reconstruction. These lesions can cause voice changes or other symptoms. The procedure is typically performed by a provider who specializes in laryngology or otolaryngology. It is important to note that this code specifically applies to the removal of non-neoplastic lesions and not neoplastic (cancerous) lesions.

5. When to use CPT code 31545

CPT code 31545 should be used when a provider performs laryngoscopy with submucosal removal of non-neoplastic lesions on the vocal cord, followed by reconstruction using local tissue flaps. This code is appropriate when the procedure is performed on an individual patient. It should not be used for neoplastic lesions or when a different technique or approach is used.

6. Documentation requirements

To support a claim for CPT 31545, the provider must document the following information:

• Patient’s diagnosis and the presence of non-neoplastic lesions on the vocal cord
• Details of the procedure, including the use of a laryngoscope and an operating microscope or telescope
• Description of the submucosal removal of the lesions and the reconstruction using local tissue flaps
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 31545, ensure that the procedure meets the criteria outlined in the official description. The use of a laryngoscope and an operating microscope or telescope is essential. It is important to note that CPT code 31545 should not be reported with other codes that describe different procedures or techniques. Additionally, it is crucial to follow the specific guidelines provided by the payer and submit all necessary documentation to support the claim.

8. Historical information

CPT 31545 was added to the Current Procedural Terminology system on January 1, 2005. There have been no updates or changes to the code since its addition.

9. Examples

1. A laryngologist performing laryngoscopy with submucosal removal of non-neoplastic lesions on the vocal cord, followed by reconstruction using local tissue flaps for a patient with vocal cord nodules.
2. An otolaryngologist performing laryngoscopy with submucosal removal of non-neoplastic lesions on the vocal cord, followed by reconstruction using local tissue flaps for a patient with vocal cord polyps.
3. A laryngologist performing laryngoscopy with submucosal removal of non-neoplastic lesions on the vocal cord, followed by reconstruction using local tissue flaps for a patient with vocal cord cysts.
4. An otolaryngologist performing laryngoscopy with submucosal removal of non-neoplastic lesions on the vocal cord, followed by reconstruction using local tissue flaps for a patient with vocal cord granulomas.
5. A laryngologist performing laryngoscopy with submucosal removal of non-neoplastic lesions on the vocal cord, followed by reconstruction using local tissue flaps for a patient with vocal cord papillomas.