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A direct laryngoscopy is a medical procedure that allows a physician to visualize the larynx and surrounding structures using a specialized instrument known as a laryngoscope. This procedure can be performed with or without the use of tracheoscopy, which involves examining the trachea. The laryngoscope can be either rigid or flexible; the choice of scope depends on the specific clinical situation. A flexible laryngoscope is typically inserted through the nostril, while a rigid laryngoscope is inserted through the mouth. During the examination, the physician inspects various anatomical areas, including the nasopharynx, oral cavity, oropharynx, hypopharynx, and larynx, for any signs of abnormalities or injuries. If any stenosis, or narrowing of the airway, is detected, the physician will identify the location and measure the length and width of the stricture. Additionally, any areas of malacia (softening of the tissue) or scarring, such as granulation tissue, will be noted. Following the visualization, a dilation laryngoscope or tracheoscope is advanced to the site of the stenosis. The conical tip of the dilation instrument is then carefully passed through the narrowed region and left in place for a duration of 5 to 10 minutes to facilitate dilation. This procedure is coded as CPT® Code 31528 for the initial dilation, while subsequent dilation procedures are coded as CPT® Code 31529.
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Direct laryngoscopy with dilation is indicated for various conditions that may affect the larynx and trachea. The following are explicitly provided indications for this procedure:
The procedure of direct laryngoscopy with dilation involves several critical steps to ensure thorough examination and treatment of the airway. The following procedural steps are outlined:
Post-procedure care following direct laryngoscopy with dilation includes monitoring the patient for any immediate complications, such as bleeding or respiratory distress. Patients may experience temporary discomfort or a sore throat following the procedure. It is essential to provide instructions regarding signs of complications that should prompt immediate medical attention. Follow-up appointments may be scheduled to assess the effectiveness of the dilation and to determine if further interventions are necessary. The physician will also review any findings from the procedure and discuss the next steps in the patient's care plan.
| Short Descr | LARYNGOSCOPY AND DILATION | Medium Descr | LARYNGOSCOPY W/WO TRACHEOSCOPY W/DILATION IN | Long Descr | Laryngoscopy direct, with or without tracheoscopy; with dilation, initial | 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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.) | 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). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AG | Primary physician | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GW | Service not related to the hospice patient's terminal condition | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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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| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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