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The procedure described by CPT® Code 31546 involves a direct laryngoscopy that is performed operatively with the aid of an operating microscope or telescope. This procedure is specifically designed for the submucosal removal of non-neoplastic lesions located on the vocal cords. The term "non-neoplastic" refers to lesions that are not cancerous, indicating that the procedure is focused on benign conditions affecting the vocal cords. During the operation, the physician utilizes a direct laryngoscope, which can be either a rigid angled scope or a flexible scope, to visualize the laryngeal structures directly. The rigid scope is typically preferred for surgical interventions and is inserted through the mouth while the patient is under general anesthesia. The examination encompasses the oral cavity, oropharynx, hypopharynx, and trachea, allowing for a comprehensive view of the vocal cords. Once the laryngoscope is positioned, an operating microscope or telescope is employed to closely examine the lesion and assess its extent. The surgical technique involves the use of specialized instruments such as micro-knives and micro-scissors to carefully incise the vocal cord tissue. The surgeon performs both blunt and sharp dissection to meticulously separate the lesion from the surrounding healthy tissue. In cases where the surgical defect is less extensive, as noted in CPT® Code 31545, a local tissue flap may be utilized to close the defect. However, in the context of CPT® Code 31546, the lesion typically involves deeper tissues, necessitating the use of an autograft for reconstruction. An autograft is a tissue graft harvested from the patient's own body, which is then prepared and placed beneath a mucosal flap to effectively reconstruct the soft tissue defect created by the lesion's removal. The mucosal flap is secured in place with sutures, ensuring proper healing and restoration of the vocal cord structure.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 31546 is indicated for the removal of non-neoplastic lesions of the vocal cords. These lesions may present as growths or abnormalities that can affect vocal function and may include conditions such as polyps, nodules, or cysts. The procedure is performed when these lesions require surgical intervention due to their size, location, or impact on the patient's voice and overall laryngeal health.
The procedure begins with the patient being placed under general anesthesia to ensure comfort and immobility during the operation. The surgeon then inserts a rigid angled or flexible direct laryngoscope through the mouth to visualize the laryngeal structures. This allows for a thorough examination of the oral cavity, oropharynx, hypopharynx, and trachea. Once the laryngoscope is in place, the vocal cords are visualized, and the laryngoscope is suspended to maintain a clear view. An operating microscope or telescope is then utilized to closely examine the lesion on the vocal cord, allowing the surgeon to assess its extent and plan the surgical approach. Following the examination, the surgeon employs micro-knives and micro-scissors to carefully incise the vocal cord tissue surrounding the lesion. This step requires precision, as the surgeon must perform both blunt and sharp dissection techniques to separate the lesion from the surrounding healthy tissue without causing unnecessary damage. Once the lesion is successfully removed, the next step involves addressing the resulting surgical defect. In this case, since the lesion involves deeper tissues, an autograft is harvested from a remote site on the patient's body, such as fat tissue. The harvested graft is then prepared for transfer and placed beneath a mucosal flap that has been created during the procedure. This flap is carefully secured in place with sutures to ensure proper healing and integration of the graft into the surrounding tissue. The use of an autograft is crucial in reconstructing the soft tissue defect, promoting optimal recovery and restoration of vocal cord function.
After the completion of the procedure, the patient is monitored in a recovery area until the effects of anesthesia wear off. Post-operative care includes managing any discomfort and monitoring for potential complications such as bleeding or infection. The patient may be advised to rest their voice and avoid strenuous activities for a specified period to promote healing. Follow-up appointments are typically scheduled to assess the healing process and ensure that the vocal cords are recovering properly. The surgeon may provide specific instructions regarding voice use and any necessary rehabilitation to restore optimal vocal function.
| Short Descr | REMOVE VC LESION SCOPE/GRAFT | Medium Descr | LARGSC MICRO/TELESCOPE RMVL LES VOCAL CORD GRAFT | Long Descr | Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining autograft) | 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 |
| 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 | 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) |
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| 2005-01-01 | Added | First appearance in code book in 2005. |
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