Outpatient Facility Coding Alert

Question: During an operative session, the surgeon performed two procedures:

• Direct laryngoscopy with microsuspension laryngoscopy and excision of bilateral vocal cord lesions
• Biopsy of left vallecular lesion. 

He used an operating microscope only for the first procedure. He excised the vallecular lesion using a cup forceps, and then brought the microscope into place for the excision of bilateral vocal cord lesions. How do I code?

Georgia Subscriber

Answer: Use only code 31541 (Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope). The other biopsy code 31535 (Laryngoscopy, direct, operative, with biopsy) is bundled into the more extensive excision code.

You don’t need to append code modifier 50 (Bilateral procedure) to 31541. The Medicare physician fee schedule specifies that bilateral reporting is not allowed for this procedure. You also won’t need modifier 59 (Distinct procedural service) since you’re only filing with one procedure code.