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A direct laryngoscopy with or without tracheoscopy is a medical procedure that allows a physician to visualize the larynx and trachea directly using a specialized instrument known as a laryngoscope. This procedure is primarily performed for the purpose of aspiration, which involves the removal of fluids or other substances from the larynx or trachea. The laryngoscope can be either rigid or flexible; the choice of scope depends on the specific clinical situation and the patient's needs. A flexible laryngoscope is typically inserted through the nostril and may be performed under local anesthesia, making it less invasive. In contrast, a rigid laryngoscope is inserted through the mouth and is usually conducted under general anesthesia, often in a surgical setting. During the procedure, the physician examines various anatomical structures, including the nasopharynx, oral cavity, oropharynx, hypopharynx, and larynx, for any signs of abnormalities such as lacerations, lesions, strictures, or other pathological conditions. If necessary, the laryngoscope may be advanced into the trachea for further examination. Following the visual assessment, the physician aspirates any fluid present in the larynx or trachea, which is then sent to a laboratory for analysis through separately reportable tests. This procedure is essential for diagnosing and managing various conditions affecting the airway and vocal structures.
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The direct laryngoscopy with or without tracheoscopy is indicated for several clinical scenarios where visualization and aspiration of the larynx or trachea are necessary. The following conditions may warrant this procedure:
The procedure of direct laryngoscopy with or without tracheoscopy involves several key steps that ensure effective visualization and aspiration:
After the completion of the direct laryngoscopy with or without tracheoscopy, the patient is monitored for any immediate complications related to the procedure. Depending on the type of anesthesia used, recovery may vary. If general anesthesia was administered, the patient will require a longer recovery period and monitoring until they are fully awake and stable. The physician may provide specific post-procedure care instructions, which could include recommendations for hydration, voice rest, and signs of complications to watch for, such as difficulty breathing or excessive bleeding. Follow-up appointments may be scheduled to discuss laboratory results and any further management required based on the findings from the procedure.
| Short Descr | LARYNGOSCOPY FOR ASPIRATION | Medium Descr | LARYNGOSCOPY W/WO TRACHEOSCOPY ASPIRATION | Long Descr | Laryngoscopy direct, with or without tracheoscopy; for aspiration | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | 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) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8H - Endoscopy - laryngoscopy | MUE | 1 | CCS Clinical Classification | 35 - Tracheoscopy and laryngoscopy with biopsy |
| 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. | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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