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Bill Posted Wed 21st of May, 2014 12:01:03 PM

If a surgeon performed 1) Direct laryngoscopy with microsuspension laryngoscopy and excision of bilateral vocal cord lesions 2) Biopsy of left vallecular lesion. He used the operating microscope for the 1st procedure, but did not for the 2nd. He excised the vallecular lesion using a cup forceps then the microscope was brought into place for the excision of bilateral vocal cord lesions. Can I code "31536" and "31535-59"? Also, would it be better to code "31541" for the excision of vocal cord lesions?

Thank you for your help

SuperCoder Answered Thu 22nd of May, 2014 09:09:54 AM

In your scenario only 31541 will be reported. The other biopsy code 31535 readily bundles into the more extensive excision code.

You may not append modifier 50 (Bilateral procedure) to 31541 (Laryngoscopy, direct,operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope). The Medicare fee schedule specifies no on bilateral for this procedure.

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