How To Use CPT Code 31578

CPT 31578 describes the procedure of laryngoscopy with the removal of non-laser lesions using a flexible laryngoscope. 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 31578?

CPT 31578 is used to describe a specific procedure involving the use of a flexible laryngoscope to examine the larynx and remove any non-laser lesions present. This code is used when the provider visually inspects the laryngeal and hypopharyngeal structures, including the vocal folds, and performs the necessary removal of lesions without the use of a laser.

2. Official Description

The official description of CPT code 31578 is: ‘Laryngoscopy, flexible; with removal of lesion(s), non-laser.’

3. Procedure

1. The provider prepares the patient and administers anesthesia as necessary.
2. Using a flexible laryngoscope, typically inserted through the nose, the provider visualizes the laryngeal and hypopharyngeal structures, including the vocal folds.
3. If any lesions are detected, the provider carefully removes them using non-laser techniques.
4. The procedure is performed without the use of a laser.

4. Qualifying circumstances

CPT 31578 is applicable when a provider performs a laryngoscopy with the removal of non-laser lesions. This procedure is typically performed on patients who have abnormalities or lesions within the larynx or vocal folds. It is important to note that the procedure specifically excludes the use of a laser for lesion removal.

5. When to use CPT code 31578

CPT code 31578 should be used when a provider performs a laryngoscopy with the removal of non-laser lesions. It is important to ensure that the procedure is accurately documented and meets the specific criteria outlined in the code description. If the procedure involves the use of a laser for lesion removal, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT code 31578, the provider must document the following information:

• Indication for the procedure and the presence of non-laser lesions
• Details of the laryngoscopy procedure, including the use of a flexible laryngoscope
• Description of the lesions removed and the technique used
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 31578, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The use of a laser for lesion removal is not included in this code and should be billed separately if applicable. Additionally, if an otolaryngology exam is performed in conjunction with the procedure, modifier 25 may be used to indicate that the examination was beyond the minor history exam and medical decision making already included in the procedure.

8. Historical information

CPT code 31578 was added to the Current Procedural Terminology system on January 1, 1990. The code description was updated on January 1, 2017 to clarify the removal of non-laser lesions.

9. Examples

1. A provider performs a laryngoscopy with the removal of non-laser lesions in a patient with vocal fold nodules.
2. During a laryngoscopy procedure, a provider identifies and removes non-laser lesions in a patient with laryngeal papillomatosis.
3. A provider performs a laryngoscopy with the removal of non-laser lesions in a patient with vocal fold polyps.
4. During a laryngoscopy procedure, a provider detects and removes non-laser lesions in a patient with laryngeal granulomas.
5. A provider performs a laryngoscopy with the removal of non-laser lesions in a patient with vocal fold cysts.
6. During a laryngoscopy procedure, a provider identifies and removes non-laser lesions in a patient with laryngeal leukoplakia.
7. A provider performs a laryngoscopy with the removal of non-laser lesions in a patient with vocal fold hemorrhage.
8. During a laryngoscopy procedure, a provider detects and removes non-laser lesions in a patient with laryngeal polyps.
9. A provider performs a laryngoscopy with the removal of non-laser lesions in a patient with vocal fold paralysis.
10. During a laryngoscopy procedure, a provider identifies and removes non-laser lesions in a patient with laryngeal stenosis.