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Susan Posted Tue 16th of January, 2018 13:07:52 PM
My physician just did a microlaryngoscopy with sinus ablation closure of a 4th brachial cleft sinus cyst/fistula. How would I code this?
SuperCoder Answered Wed 17th of January, 2018 08:40:53 AM

The exact coding would depend upon the details of this case. Generally, microlaryngoscopy means a close or microscopic view of the larynx. Laryngoscopy codes are divided according to types: indirect (31505-31513), direct (31515-31571) and flexible (31575-31579). 

Only direct laryngoscopy codes include using a microscope, therefore microlaryngoscopy is basically direct laryngoscopy with an operating microscope. So, in this case, codes from range 31515-31571 should be considered.

For branchial cleft anomaly excision, there are two procedure codes available, 42810 and 42815.

Please correlate with the details of your case. Thank you.

Susan Posted Wed 17th of January, 2018 11:45:28 AM
My doctor did not excise the branchial cleft cyst, he did an ablation using the laryngoscope. I have looked at the scope codes and the excision codes, none of these codes are close to what he did. Is this one that needs an listed procedure code?
SuperCoder Answered Thu 18th of January, 2018 00:26:21 AM

Please send complete procedure details for us to assist with the correct code(s). Thank you.

Susan Posted Fri 19th of January, 2018 18:02:41 PM
The laryngoscope was suspend in the pifiorm sinus. Under visualization the sinus was cauterized to the depth of 4 mm using needle-tip electrocautery. He then placed a 5-0 chromic suture endoscopically. There was no excision of the branchial cleft cyst.
SuperCoder Answered Wed 24th of January, 2018 07:35:08 AM

Codes to bill for this procedure should be 31599 (Unlisted procedure, larynx) along with 69990 (Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure). Also, you should include a cover letter stating why you are using the unlisted procedure code. This separate report should explain, in simple, straightforward language, exactly what the physician did.

Thank you.

Susan Posted Wed 24th of January, 2018 12:13:01 PM
Thank you for your help.
SuperCoder Answered Thu 25th of January, 2018 00:12:10 AM
Happy to help.

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