© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 31545 involves a direct laryngoscopy, which is a surgical technique that allows a physician to visualize the larynx and vocal cords directly using specialized instruments. This procedure is performed with the aid of an operating microscope or telescope, enhancing the surgeon's ability to see and operate on the vocal cords with precision. The primary focus of this procedure is the submucosal removal of non-neoplastic lesions located on the vocal cords. Non-neoplastic lesions refer to abnormal growths that are not cancerous, which can affect vocal cord function and overall voice quality. During the procedure, the surgeon utilizes a rigid or flexible laryngoscope, typically inserted through the mouth under general anesthesia, to examine the oral cavity, oropharynx, hypopharynx, and trachea. Once the lesion is identified, instruments such as micro-knives or micro-scissors are employed to carefully incise the vocal cord tissue. The surgeon then uses both blunt and sharp dissection techniques to separate the lesion from the surrounding healthy tissue. After the lesion is excised, the surgical defect is reconstructed using local tissue flaps. This involves developing, trimming, and advancing or rotating a flap of local tissue over the defect, which is then secured in place with sutures. This meticulous approach aims to restore the integrity of the vocal cords while minimizing complications and promoting optimal healing.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 31545 is indicated for the removal of non-neoplastic lesions of the vocal cords. These lesions may present with various symptoms that necessitate surgical intervention, including:
The procedure for CPT® Code 31545 involves several critical steps to ensure the effective removal of the lesion and reconstruction of the vocal cord. The steps are as follows:
Post-procedure care following CPT® Code 31545 involves monitoring the patient for any immediate complications related to the surgery. Patients may experience some swelling and discomfort in the throat, which is typically managed with pain relief medications. Voice rest is often recommended for a specified period to allow the vocal cords to heal properly. Follow-up appointments are essential to assess the healing process and ensure that the vocal cords are functioning correctly. The surgeon may provide specific instructions regarding activity restrictions and signs of complications that should prompt immediate medical attention.
| Short Descr | REMOVE VC LESION W/SCOPE | Medium Descr | LARGSC MICRO/TELESCOPE RMVL LES VOCAL CORD FLAP | Long Descr | Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s) | 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) | 1 - 150% payment adjustment for bilateral procedures applies. | 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. | Endoscopic Base Code | 31526 Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope | 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 42 - Other OR therapeutic procedures on respiratory system |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. 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. | 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). | 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). | 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.) | AG | Primary physician | 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 | 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) | SG | Ambulatory surgical center (asc) facility service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2005-01-01 | Added | First appearance in code book in 2005. |
Get instant expert-level medical coding assistance.