Otolaryngology Coding Alert

Plus, know what circumstances warrant reporting an unlisted code.

Knowing your way around the broad assortment of laryngoscopy codes is an important part of being a successful otolaryngology coder. If you’ve got experience coding laryngoscopic services for your providers, you understand the different challenges coders may face on their search for the most accurate CPT^® code. Coding laryngoscopic services is additionally tricky due to the numerous surgical subsections you’ve got to navigate through.

One of those subsections, microlaryngoscopies, is nuanced enough to trip up the most experienced ENT coders. If the existing code set isn’t comprehensive enough, you’ve also got to know what microlaryngoscopic coding circumstances call for the use of an unlisted CPT^® code.

Refresh your laryngoscopic/microlaryngoscopic coding knowledge and hone in on two examples of when you’ve got no choice but to resort to reporting an unlisted code.

Distinguish 3 Types of Laryngoscopy Services

First, here’s a refresher on the various types of laryngoscopies your provider may perform in the office.

• Indirect laryngoscopy involves use of a mirror or laryngeal, angled telescope to examine the larynx in a “look around the corner” manner. This procedure is typically performed in the office and is considered part of an ENT exam (bundled in the evaluation and management [E/M] visit). You should not separately bill for an indirect laryngoscopy.
• Direct laryngoscopy involves the use of a rigid laryngoscope that is hollowed out to allow instruments and lighted tubes to pass through to view the larynx and perform procedures if necessary. The direct laryngoscope is inserted directly into the patient’s mouth as access to the larynx and associated structures. “This procedure is typically performed in the operating room under general anesthesia and may require use of the operating microscope or telescope,” says Jennifer M. Connell, CPC, COC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, CEMA, owner of E2E Health Solutions in Victoria, Texas. “When a microscope or telescope is used, this is often referred to as a microlaryngoscopy,” Connell notes.
• Flexible laryngoscopy involves use of a flexible fiberoptic or distal-chip laryngoscope that usually is connected to a camera that allows for video recording and viewing of the larynx. The flexible laryngoscope is inserted through the nose and threaded down into the nasopharynx, to the larynx.

Carefully Consider Between Multiple Microlaryngoscopy Codes

Distinguishing between direct, indirect, and flexible laryngoscopy services can certainly be challenging given the extent of the operative report, but the problem doesn’t end there. You may also experience frustration identifying when, and when not, to report a particular microlaryngoscopy code for your provider’s services.

The nine existing, sometimes competing microlaryngoscopy codes within the CPT^® manual are as follows:

• 31526 — Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope
• 31531 — Laryngoscopy, direct, operative, with foreign body removal; with operating microscope or telescope
• 31536 — Laryngoscopy, direct, operative, with biopsy; with operating microscope or telescope
• 31541 — Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope
• 31571 — Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope
• 31561 — Laryngoscopy, direct, operative, with arytenoidectomy; with operating microscope or telescope
• 31545 — 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)
• 31546 — 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)
• 31561 — Laryngoscopy, direct, operative, with arytenoidectomy; with operating microscope or telescope.

Know When to Fall Back on 31599

There are various clinical encounters that will require you to compare and contrast each of the nine microlaryngoscopic CPT^® codes, ultimately to reach the conclusion that none completely describe the surgical services at hand. That’s when code 31599 (Unlisted procedure, larynx) comes into play.

Example: Excision of the aryepiglottic fold arytenoid mucosa due to laryngomalacia.

You’ll have to rely on further details within the operative report to determine whether or not to report an existing CPT^® code or an unlisted code. For instance, if the provider documents the use of a laryngoscope with or without an operating microscope or telescope to excise arytenoid mucosa, you should report either 31560 (Laryngoscopy, direct, operative, with arytenoidectomy) or 31561. However, if the procedure is performed without the use of a laryngoscope, you will have to resort to reporting the unlisted code 31599. This operation is also known as a supraglottoplasty.

There is currently no CPT^® code in circulation that you may use to report a supraglottoplasty. Instead, you will report code 31599 and use the most appropriate comparison code to achieve proper reimbursement for your provider’s services. In this example, you may consider code 31560 or 31561 as suitable comparison code options to include in Box 19 of the CMS1500 Claim Form.

Coder’s note: Do not consider codes 31540 (Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis) or 31541 if the provider performs a supraglottoplasty service with a laryngoscope. Report the 31540/31541 codes if the service is performed on the epiglottis. In this example, the excision is being performed on a portion of the arytenoid cartilages known as the arytenoid epiglottic fold, a separate site from that of the epiglottis.

“The aryepiglottic folds are triangular folds of mucous membrane enclosing ligamentous and muscular fibers that are located at the entrance of the larynx extending from the borders of the epiglottis to the arytenoid cartilages,” explains Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center’s Department of Otolaryngology in Rochester, New York. “Hence, the name aryepiglottic, which is not to be confused with the epiglottis,” says Quinlan.

Example: Microlaryngoscopy with laser excision of subglottic stenosis.

Here’s another example of when the line between using an existing and unlisted CPT^® code can become blurry. Reading the code description for 31541, it’s easy to see how you may get tripped up on the most accurate code to report.

Based on the code description, you might assume that, in order to report code 31541, the provider must perform a surgical excision of a known tumor. However, the clinical responsibility under code 31541 states that the provider “identifies the tumor or other abnormality in the vocal cord or epiglottis.” Based on this wording, you may consider 31541 appropriate when considering a code for a microlaryngoscopy with laser excision of subglottic stenosis.