How To Use CPT Code 31546

CPT 31546 describes the operative procedure of laryngoscopy with submucosal removal of non-neoplastic lesions of the vocal cord, along with reconstruction using grafts. 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 31546?

CPT 31546 is used to describe a surgical procedure in which a healthcare provider uses laryngoscopy, an examination technique using a flexible tube-shaped endoscope with a camera, to visualize the larynx. The provider also utilizes an operating microscope or telescope to assist in the procedure. During the surgery, the provider removes one or more non-neoplastic lesions, such as polyps, from the vocal cord. Additionally, the provider reconstructs the defect left after lesion removal by obtaining a graft, which may involve using autografts. It is important to note that CPT 31546 should not be reported in conjunction with certain other codes related to graft harvest.

2. Official Description

The official description of CPT code 31546 is: ‘Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining autograft).’ It is important to remember not to report CPT 31546 in conjunction with specific codes related to graft harvest or reconstruction with allograft.

3. Procedure

1. The healthcare provider prepares the patient for the procedure, ensuring appropriate anesthesia and positioning.
2. The provider inserts a flexible tube-shaped endoscope with a camera through the nose or mouth and advances it into the throat to visualize the larynx.
3. Using an operating microscope or telescope, the provider carefully examines the mucus lining or covering of the oral cavity, oropharynx, hypopharynx, and larynx to identify any abnormality.
4. If non-neoplastic lesions are present on the vocal cord, the provider injects a solution of saline and adrenaline beneath the surface of the vocal fold to define the lesions and protect the deeper vocal cords.
5. The provider isolates the lesion and creates an incision over the mucosa, carefully dissecting the lesion while protecting the vocal cord.
6. To reconstruct the defect left after lesion removal, the provider obtains a graft, which may involve using autografts.
7. The provider uses the graft to reconstruct the defect, ensuring proper placement and closure.
8. After completing the procedure, the provider removes all instruments and monitors the patient for vital signs.

4. Qualifying circumstances

CPT 31546 is typically performed on patients who have non-neoplastic lesions on their vocal cords that require surgical removal and reconstruction. These lesions may include polyps or other benign growths. The procedure is performed by a healthcare provider who is skilled in laryngoscopy and has the necessary equipment, such as an operating microscope or telescope. The use of grafts, including autografts, for reconstruction is also a qualifying circumstance for this procedure.

5. When to use CPT code 31546

CPT code 31546 should be used when a healthcare provider performs laryngoscopy with submucosal removal of non-neoplastic lesions of the vocal cord and reconstructs the defect using grafts, including autografts. It is important to note that this code should not be reported in conjunction with certain other codes related to graft harvest or reconstruction with allograft.

6. Documentation requirements

To support a claim for CPT 31546, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for laryngoscopy with submucosal removal of non-neoplastic lesions of the vocal cord
• Details of the procedure, including the use of an operating microscope or telescope
• Specific graft(s) used for reconstruction, including whether autografts were obtained
• Date and duration of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 31546, ensure that the procedure meets the criteria outlined in the official description. It is important to note that CPT 31546 should not be reported in conjunction with certain other codes related to graft harvest or reconstruction with allograft. Pay attention to any specific guidelines provided by payers regarding the use of this code. Proper documentation is essential to support the claim for reimbursement.

8. Historical information

CPT 31546 was added to the Current Procedural Terminology system on January 1, 2005. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs laryngoscopy with submucosal removal of non-neoplastic lesions of the vocal cord and reconstructs the defect using autografts.
2. During the procedure, the provider identifies and removes multiple non-neoplastic lesions from the vocal cord, followed by reconstruction using grafts.
3. A patient undergoes laryngoscopy with submucosal removal of a non-neoplastic lesion of the vocal cord and reconstruction with a graft obtained from another part of their body.
4. The healthcare provider performs laryngoscopy with submucosal removal of non-neoplastic lesions of the vocal cord and reconstructs the defect using autografts obtained from the patient’s own tissue.
5. During the procedure, the provider removes a large non-neoplastic lesion from the vocal cord and reconstructs the defect using grafts.