2025 CPT code 31536
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Respiratory System Surgery Feed
Direct laryngoscopy with biopsy; using operating microscope or telescope.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 59 for distinct procedural services, 22 for increased procedural services).
Medical necessity is established when a lesion or area of concern in the larynx or hypopharynx requires histopathological examination to diagnose or manage a suspected condition. This is generally based on patient symptoms and clinical findings.
The physician performs the direct laryngoscopy, identifies the target tissue, obtains the biopsy sample using instruments such as microscissors, controls any bleeding, and removes the laryngoscope.
In simple words: The doctor uses a special tool to look directly into your voice box (larynx) and throat.They then take a small tissue sample (biopsy) from an abnormal area to check for disease.A microscope or telescope helps the doctor see better.
This procedure involves direct visualization of the larynx and hypopharynx using a laryngoscope.A biopsy is performed, removing a tissue sample from a lesion or other target area within the larynx or hypopharynx. An operating microscope or telescope is utilized to enhance visualization during the procedure.Bleeding is controlled, and the laryngoscope is removed.
Example 1: A patient presents with a suspicious lesion on a vocal cord.The physician performs a direct laryngoscopy with biopsy using an operating microscope to obtain a tissue sample for pathological examination., A patient complains of persistent hoarseness.A direct laryngoscopy with biopsy, aided by a telescope, is performed to visualize and sample an area of suspected dysplasia in the larynx., During a routine laryngoscopy, an unexpected lesion is found in the pyriform sinus.A biopsy is taken using an operating microscope, and the sample is sent for histopathological analysis.
* Preoperative and postoperative diagnosis.* Description of the lesion or area biopsied.* Indication for the procedure (e.g., hoarseness, dysphagia, suspicious lesion).* Type of instrument used (microscope, telescope, or both).* Specimen description and location (if applicable).* Pathology report results.
** The use of an operating microscope or telescope is integral to the code and impacts reimbursement.Careful documentation is crucial for accurate coding and payment.
- Revenue Code: P8H (ENDOSCOPY - LARYNGOSCOPY)
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier might apply depending on the billing setting and who is performing the procedure (physician, anesthesiologist, etc.).
- Specialties:Otolaryngology, Head and Neck Surgery
- Place of Service:Ambulatory Surgical Center, Hospital (Inpatient and Outpatient), Office