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2025 CPT code 31578

Laryngoscopy, flexible; with removal of lesion(s), non-laser.

Code 31578 is specifically for removal of lesions using non-laser techniques. If a laser is used, a different code is required. When performed endoscopically, report appropriate endoscopy code(s) for each site examined. For diagnostic laryngoscopy with biopsy, use 31575. For laryngoscopy with operating microscope or telescope, use appropriate code only once per session. All paired laryngeal structures on one side are considered unilateral for therapeutic interventions. Modifier 59 may be necessary to distinguish this procedure from other procedures performed during the same session.

Modifiers may be applicable. Modifier 22 may be used for increased procedural services, modifier 59 may be used to indicate a distinct procedural service, and modifier 25 may be used if a separately identifiable E/M service is provided on the same day. Use appropriate modifiers when additional procedures are also done for which other codes apply, like 51, according to standard guidelines.

The physician is responsible for preparing and anesthetizing the patient, inserting the flexible laryngoscope, visualizing the laryngeal and hypopharyngeal structures, and removing any lesions without using a laser. This requires specialized training in otolaryngology and expertise in using flexible laryngoscopes and other surgical instruments within the delicate structures of the larynx.

In simple words: The doctor uses a thin, flexible tube with a camera to look at your voice box and remove any abnormal growths without using a laser.

This code describes a procedure where a physician uses a flexible laryngoscope to visualize the larynx and remove lesions (abnormal tissue) without the use of a laser. The procedure involves inserting the laryngoscope, usually through the nose, to examine the larynx and hypopharynx, including the vocal folds. The physician then removes any identified lesion(s) using appropriate instruments.

Example 1: A patient presents with hoarseness and a small vocal cord polyp is discovered during a flexible laryngoscopy. The polyp is removed during the same procedure using 31578., A patient with a history of vocal cord nodules has a recurrence. The physician uses a flexible laryngoscopy to assess and remove the nodules using non-laser techniques (31578). , A patient has a benign laryngeal lesion causing discomfort. The physician performs a flexible laryngoscopy and removes the lesion without a laser, coding the procedure as 31578.

Documentation should include details of the flexible laryngoscopy findings, the size and location of the lesion(s), the method of removal, and any complications encountered. The medical necessity of the procedure should also be clearly documented, including the symptoms and impact on the patient's voice or airway. If an E/M service is billed with modifier 25, the documentation should clearly demonstrate that it was a significant, separately identifiable service above and beyond the work associated with the procedure itself.

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