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The procedure described by CPT® Code 31576 refers to a flexible laryngoscopy that includes the performance of biopsy(ies). This diagnostic procedure utilizes a flexible laryngoscope, which is a thin, tube-like instrument equipped with a light and camera, allowing for visualization of the larynx and surrounding structures. The process begins with the application of a topical anesthetic to the nasal cavity, palate, and posterior pharynx to minimize discomfort for the patient. Following this, the laryngoscope is carefully introduced through the nose, and additional anesthetic is applied to the base of the tongue and larynx using fiberoptic guidance to ensure adequate numbing. Once the anesthetic has taken effect, the flexible laryngoscope is reinserted to examine the pharynx, vocal cords, tongue base, and hypopharynx for any signs of disease or injury. During this examination, the patient may be asked to sing or speak, which aids in better visualization of the vocal cords. In the context of CPT® Code 31576, the procedure is further advanced to include the collection of biopsy samples. A fine biopsy instrument is maneuvered through the working channel of the laryngoscope to obtain one or more tissue samples from any suspicious areas identified during the examination, ensuring that normal tissue is preserved as much as possible. This biopsy is crucial for pathological examination to determine the presence of any abnormalities or diseases affecting the laryngeal region.
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The flexible laryngoscopy with biopsy(ies) as described by CPT® Code 31576 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 for flexible laryngoscopy with biopsy(ies) involves several key steps that ensure thorough examination and sample collection. Each step is critical for achieving accurate diagnostic results.
Following the flexible laryngoscopy with biopsy(ies), patients may experience some temporary discomfort or a sore throat due to the procedure. It is important for healthcare providers to monitor the patient for any immediate complications, such as excessive bleeding or difficulty breathing. Patients are typically advised to avoid irritants such as smoke and to refrain from consuming hot or spicy foods for a short period post-procedure. Additionally, the clinician may provide specific instructions regarding follow-up appointments to discuss biopsy results and any further management that may be necessary based on the findings.
| Short Descr | LARYNGOSCOPY WITH BIOPSY | Medium Descr | LARYNGOSCOPY FLEXIBLE W/BIOPSY(IES) | Long Descr | Laryngoscopy, flexible; with biopsy(ies) | 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) | 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 | 31575 Laryngoscopy, flexible; diagnostic | 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 | 35 - Tracheoscopy and laryngoscopy with biopsy |
| 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). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) 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). | 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. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | 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) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) | 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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| 2017-01-01 | Changed | Long and Medium descriptions changed. Guidelines Changed. |
| Pre-1990 | Added | Code added. |
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