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The procedure described by CPT® Code 31365 refers to a total laryngectomy performed in conjunction with a radical neck dissection (RND). In this surgical intervention, the entire larynx, commonly known as the voice box, is completely excised. The operation begins with a horizontal incision made in the skin of the neck, specifically at the level of the thyroid cartilage, which is a prominent structure in the neck. Following the incision, subplatysmal flaps are raised to expose the larynx, allowing the surgeon to carefully dissect it free from the surrounding tissues. During this process, several critical anatomical structures are addressed: the delphian node is removed, the thyroid gland is resected, and the hyoid bone is excised. Additionally, the thyroid cartilage is skeletonized to facilitate access to the larynx. The entry point into the larynx is determined by the specific location and extent of the disease being treated. Once the larynx is fully accessed, it is removed in its entirety. After the laryngectomy, the surgical wound is closed, and a laryngostoma is created. This involves making a separate incision below the initial laryngectomy incision, through which the trachea is externalized and sutured to the skin at the sternal notch. This procedure results in a permanent stoma, allowing the patient to breathe directly through the trachea, bypassing the removed larynx. It is important to note that CPT® Code 31360 is designated for cases where a total laryngectomy is performed without the accompanying radical neck dissection, while CPT® Code 31365 is specifically used when RND is included in the surgical approach. The radical neck dissection typically involves the excision of lymph node groups levels I-V, as well as the removal of the sternocleidomastoid muscle, internal jugular vein, submandibular gland, and potentially other muscles such as the anterior belly of the digastric, sternohyoid, and sternothyroid muscles.
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The total laryngectomy with radical neck dissection (CPT® Code 31365) is indicated for patients diagnosed with advanced laryngeal cancer or other malignancies affecting the larynx that necessitate the complete removal of the larynx and surrounding lymphatic structures. This procedure is typically performed when there is evidence of extensive disease that may involve the lymph nodes in the neck, requiring a comprehensive surgical approach to ensure complete excision of cancerous tissues and to prevent metastasis.
The procedure for a total laryngectomy with radical neck dissection involves several critical steps that ensure the complete removal of the larynx and associated structures. The first step is to make a horizontal incision in the skin of the neck at the level of the thyroid cartilage. This incision allows access to the underlying tissues. Following the incision, subplatysmal flaps are raised, which involves lifting the skin and subcutaneous tissue to expose the larynx. The surgeon then carefully dissects the larynx free from surrounding tissues, ensuring that all anatomical structures are preserved as necessary for the procedure. Next, the delphian node is excised, which is a lymph node located in the midline of the neck, often involved in the spread of head and neck cancers. The thyroid gland is also resected during this procedure, as it may be affected by the disease. The hyoid bone, which supports the tongue and is located above the larynx, is removed to facilitate access to the larynx. The thyroid cartilage is then skeletonized, meaning that the surrounding soft tissues are carefully removed to expose the cartilage itself. Once the larynx is fully accessed, the surgeon enters the larynx, with the specific site of entry determined by the extent and location of the disease. The larynx is then completely removed from the body. After the laryngectomy is performed, the surgical wound is closed, and a laryngostoma is created. This involves making a separate incision below the initial incision for the laryngectomy. The trachea is then externalized and sutured to the skin at the sternal notch, creating a permanent stoma that allows the patient to breathe directly through the trachea, bypassing the removed larynx. In conjunction with the total laryngectomy, the radical neck dissection is performed, which typically involves the excision of lymph node groups levels I-V. The surgeon dissects these lymph node groups free of surrounding tissue and excises them to ensure that any cancerous lymph nodes are removed. Additionally, the sternocleidomastoid muscle and the internal jugular vein may be removed during this procedure, along with the submandibular gland. The anterior belly of the digastric muscle, as well as the sternohyoid and sternothyroid muscles, may also be excised as part of the radical neck dissection to achieve complete removal of affected tissues.
After the total laryngectomy with radical neck dissection, patients typically require close monitoring and care to manage their recovery. Post-operative care includes monitoring for complications such as bleeding, infection, and respiratory issues due to the creation of the laryngostoma. Patients will need to be educated on stoma care and how to manage breathing through the stoma. Recovery may involve a stay in the hospital for several days, during which time the surgical site will be assessed for healing and any potential complications. Patients may also require speech therapy to adapt to changes in their ability to communicate, as the removal of the larynx eliminates the natural voice. Additionally, follow-up appointments will be necessary to monitor for any signs of recurrence of cancer and to manage any ongoing health issues related to the surgery. Overall, the post-procedure phase is critical for ensuring a successful recovery and adaptation to the changes resulting from the surgery.
| Short Descr | REMOVAL OF LARYNX | Medium Descr | LARYNGECTOMY TOTAL W/RADICAL NECK DISSECTION | Long Descr | Laryngectomy; total, with radical neck dissection | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 42 - Other OR therapeutic procedures on respiratory system |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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