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The procedure described by CPT® Code 31368 involves a subtotal supraglottic laryngectomy (SGL) combined with a radical neck dissection (RND). This surgical intervention is primarily indicated for the treatment of cancer that originates from specific areas of the larynx, including the epiglottis, aryepiglottic folds, and false vocal cords. The goal of the subtotal supraglottic laryngectomy is to excise the cancerous tissue while preserving essential laryngeal functions, which include airway protection, respiration, and the ability to produce sound (phonation). Prior to the laryngectomy, a tracheostomy is performed to ensure that the airway remains secure and separate from the surgical site. The procedure involves a series of meticulous steps, including the creation of a horizontal incision in the neck, the careful dissection of surrounding tissues, and the removal of the affected laryngeal structures. The radical neck dissection component entails the removal of lymph nodes and surrounding tissues to ensure comprehensive cancer treatment. This combination of procedures is critical for managing advanced laryngeal cancers and optimizing patient outcomes.
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The subtotal supraglottic laryngectomy with radical neck dissection is indicated for patients diagnosed with cancer affecting specific regions of the larynx. The following conditions may warrant this surgical intervention:
The surgical procedure for CPT® Code 31368 involves several critical steps to ensure effective removal of cancerous tissues while preserving vital functions:
After the subtotal supraglottic laryngectomy with radical neck dissection, patients typically require careful monitoring and management. Post-operative care includes monitoring for complications such as bleeding, infection, and airway obstruction. Patients may need assistance with breathing and swallowing as they recover from the surgery. The presence of drains will help manage any fluid accumulation at the surgical site. Follow-up appointments are essential to assess healing and to plan for any necessary rehabilitation, including speech therapy, to aid in recovery of voice function. The overall recovery process may vary based on individual patient factors and the extent of the surgery performed.
| Short Descr | PARTIAL REMOVAL OF LARYNX | Medium Descr | LARYNGECTOMY STOT SUPRAGLOTTIC W/RAD NCK DSJ | Long Descr | Laryngectomy; subtotal supraglottic, 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 |
| 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). | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| Pre-1990 | Added | Code added. |
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