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A direct laryngoscopy with insertion of an obturator, with or without tracheoscopy, is a procedure that allows a physician to directly visualize the larynx and surrounding structures using a specialized instrument known as a laryngoscope. This procedure is essential for examining the upper airway, including the nasopharynx, oral cavity, oropharynx, hypopharynx, and larynx, for any signs of abnormalities or injuries. The laryngoscope can be either rigid or flexible; the rigid angled scope is typically inserted through the mouth, while the flexible scope is inserted through the nostril. The use of fiberoptics in the laryngoscope enhances the visualization of these structures, enabling the physician to detect conditions such as lacerations, lesions, strictures, or other pathologies. In cases where the examination extends into the trachea, the physician may advance the scope further to assess the tracheal structures. The insertion of an obturator is a critical component of this procedure, as it helps to maintain an open airway during the examination, ensuring that the patient can breathe adequately while the procedure is being performed.
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The procedure of direct laryngoscopy with insertion of an obturator, with or without tracheoscopy, is indicated for various clinical scenarios where direct visualization of the larynx and surrounding structures is necessary. The following conditions may warrant this procedure:
The procedure of direct laryngoscopy with insertion of an obturator involves several key steps that ensure effective visualization and examination of the larynx and trachea. The following procedural steps are typically followed:
Following the direct laryngoscopy with insertion of an obturator, patients are typically monitored for any adverse effects or complications that may arise from the procedure. Common post-procedure care includes observing the patient for signs of respiratory distress, bleeding, or infection. Patients may experience temporary hoarseness or throat discomfort, which is generally expected and resolves on its own. Instructions regarding diet, activity level, and follow-up appointments are provided to ensure proper recovery and management of any underlying conditions that were assessed during the procedure.
| Short Descr | LARYNGOSCOPY FOR TREATMENT | Medium Descr | LARYNGOSCOPY W/WO TRACHEOSCOPY INSERT OBTURATOR | Long Descr | Laryngoscopy direct, with or without tracheoscopy; with insertion of obturator | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic 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) | 0 - 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. | Endoscopic Base Code | 31525 Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | 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 | 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). | 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.) | 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 | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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