Otolaryngology Coding Alert

Question: What’s the coding for a suspension microlaryngoscopy with excision and biopsy of a laryngeal polyp?

Kansas Subscriber              

Answer: You’ll need access to the operative report to definitively answer this question. If the surgeon performs a complete excision of a laryngeal polyp, then you’d be justified in reporting code 31541 (Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope). Since a tumor can be a neoplasm of benign or malignant nature, a polyp does meet the criteria to be considered a tumor.

So long as you have documentation that the entirety of the polyp was excised, you will report code 31541. Furthermore a biopsy is considered an inclusive component of this service. If the provider documents that only a portion of the polyp was excised for biopsy purposes, you will instead report code 31535 (Laryngoscopy, direct, operative, with biopsy) or 31536 (… with operating microscope or telescope), depending on use of an operating microscope.