2025 CPT code 31546
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Respiratory System Feed
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).
Modifiers may be applicable. Common modifiers include 22 (Increased Procedural Services), 50 (Bilateral Procedure), 51 (Multiple Procedures), etc. Refer to current CPT guidelines for proper modifier usage.
Medical necessity should be established by documenting the symptoms caused by the lesion, such as hoarseness, voice changes, or breathing difficulties.The documentation should clearly link the procedure to the improvement of the patient's condition.
The physician is responsible for preparing the patient, administering anesthesia, performing the laryngoscopy and lesion removal, obtaining and placing the graft, and post-operative care.
In simple words: This procedure involves examining the voice box with a special lighted scope and magnifying instruments.The doctor removes non-cancerous growths from the vocal cord(s) and then repairs the area with a small tissue graft taken from elsewhere in the throat.
This code describes a procedure where the physician performs a direct laryngoscopy using an operating microscope or telescope. During the procedure, they remove one or more benign (non-cancerous) lesions from the vocal cord(s).The resulting defect is then reconstructed using a graft, which is also obtained during the procedure. This often involves taking a small piece of mucosal tissue from another area in the mouth or throat (autograft).
Example 1: A patient with a benign vocal cord polyp causing hoarseness undergoes microlaryngoscopy with polyp removal and reconstruction with a mucosal graft., A singer with a vocal cord nodule impacting their voice undergoes this procedure to have the nodule removed and their vocal cord repaired., A patient with a granuloma on their vocal cord undergoes this procedure to have it removed and the area reconstructed.
Documentation should include details of the laryngoscopy, the size and location of the lesion(s), the type of graft used, the method of reconstruction, and any complications.
- Revenue Code: P1G (Berenson-Eggers Type of Service (BETOS): Surgical - Other Major Procedures, as of today's date.)
- Specialties:Otolaryngology (ENT)
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Physician's Office