Crystal's MCW Coder Hub👩🏾⚕️ CPT 31360: Laryngectomy; total, without radical neck dissection
Short Definition
Total laryngectomy without radical neck dissection — complete surgical removal of the entire larynx (voice box), including the epiglottis, thyroid cartilage, cricoid cartilage, arytenoid cartilages, and hyoid bone, with permanent tracheostomy creation, performed without concurrent radical neck dissection. The primary indication is laryngeal malignancy not amenable to organ preservation or partial resection.
Full CPT Descriptor
Laryngectomy; total, without radical neck dissection
Long Clinical Definition
CPT 31360 describes a total laryngectomy (TL) — the complete, irreversible en bloc removal of the laryngeal complex with creation of a permanent end tracheostomy in the anterior neck. It is one of the most anatomically and functionally transformative procedures in head and neck surgery. Following total laryngectomy, the patient:
- Breathes permanently through a tracheostoma in the neck — the upper airway is completely separated from the digestive tract.
- Has no natural voice — alaryngeal communication must be established through tracheoesophageal voice prosthesis (TEP/Blom-Singer device), esophageal speech, or electrolarynx.
- Has permanently altered sense of smell and taste due to nasal airflow diversion.
Structures removed in a standard total laryngectomy:
- Epiglottis (and pre-epiglottic space when involved).
- Hyoid bone (typically removed for oncologic margin).
- Thyroid cartilage (entire framework).
- Cricoid cartilage (entire ring).
- Arytenoid cartilages (bilateral).
- True and false vocal folds.
- Subglottic mucosa.
- Proximal tracheal rings (1-2 rings, incorporated into the tracheostoma).
- Thyroid gland lobes or isthmus — when overlying or adherent to the larynx (if thyroid is separately resected, see thyroid coding nuance section).
- Strap muscles (as needed for oncologic margin or access).
The permanent end tracheostoma is matured by suturing the tracheal mucosa to the skin of the anterior lower neck — this is the patient’s sole airway for life.
“Without radical neck dissection” in the CPT descriptor means:
- No concurrent ipsilateral or bilateral formal neck dissection (Levels I-V, removing SCM, IJV, and CN XI) is included in 31360.
- Limited or selective neck dissection, modified radical neck dissection, or central neck dissection may still be performed — see the neck dissection nuance section below for the critical coding distinction.
Primary Indications
| Indication | ICD-10-CM | Notes |
|---|---|---|
| T3-T4 squamous cell carcinoma of glottis | C32.0 | Most common indication |
| T3-T4 squamous cell carcinoma of supraglottis | C32.1 | Supraglottic laryngeal SCC |
| T3-T4 squamous cell carcinoma of subglottis | C32.2 | Less common |
| Laryngeal SCC at overlapping subsites | C32.8 | Tumor spanning multiple subsites |
| Laryngeal cartilage malignancy | C32.3 | Chondrosarcoma, etc. |
| Recurrent laryngeal cancer after prior radiation or chemoradiation | C32.x | Salvage laryngectomy — highest complexity |
| Recurrent laryngeal cancer after prior partial laryngectomy | C32.x | Completion laryngectomy |
| Dysfunctional larynx causing chronic aspiration | J69.0 | Non-oncologic — aspiration laryngectomy |
| Laryngeal stenosis with failed reconstruction, ventilator-dependent | J38.6 | Benign functional indication |
| Chondroradionecrosis — laryngeal necrosis post-radiation | M87.38 | Late radiation complication |
CPT Code Family — Laryngectomy Ladder
Laryngectomy CPT Family
│
├── PARTIAL LARYNGECTOMY (organ preservation — larynx partially preserved)
│ ├── 31370 — Partial laryngectomy; horizontal
│ ├── 31375 — Partial laryngectomy; lateralizing cartilage resection
│ ├── 31380 — Partial laryngectomy; antero-lateral vertical partial
│ └── 31382 — Partial laryngectomy; antero-lateral vertical partial, with radical neck dissection
│
├── SUBTOTAL SUPRAGLOTTIC LARYNGECTOMY
│ ├── 31367 — Laryngectomy; subtotal supraglottic, without radical neck dissection
│ └── 31368 — Laryngectomy; subtotal supraglottic, with radical neck dissection
│
├── TOTAL LARYNGECTOMY
│ ├── 31360 — Laryngectomy; total, WITHOUT radical neck dissection ← THIS NOTE
│ └── 31365 — Laryngectomy; total, WITH radical neck dissection
│
├── PHARYNGOLARYNGECTOMY (larynx + pharynx resected)
│ ├── 31390 — Pharyngolaryngectomy, with radical neck dissection; without reconstruction
│ └── 31395 — Pharyngolaryngectomy, with radical neck dissection; with reconstruction
│
├── TEP (tracheoesophageal voice prosthesis — commonly performed with 31360)
│ └── 31611 — Construction of tracheoesophageal fistula and insertion of alaryngeal speech prosthesis
│ (separately reportable add-on — see TEP section)
│
└── NECK DISSECTION (separately reportable when performed with 31360)
├── 38720 — Cervical lymphadenectomy (modified radical neck dissection) — with modifier -59
└── 38724 — Cervical lymphadenectomy (radical neck dissection) — see 31365 nuance
31360 vs. 31365 — The Most Critical Code Selection Decision
The single distinguishing factor between 31360 and 31365 is whether a RADICAL neck dissection is performed:
| Feature | 31360 | 31365 |
|---|---|---|
| Total laryngectomy | Yes | Yes |
| Radical neck dissection | No | Yes — formal radical, removing SCM + IJV + CN XI |
| Modified radical neck dissection | No — separately billable | Not described by 31365 — see MRND nuance |
| Selective neck dissection | No — separately billable | Not described by 31365 |
| wRVU (approx 2026) | ~26.35 | ~29.50 |
| Global period | 090 | 090 |
MRND (modified radical neck dissection) with total laryngectomy — the billing gray zone:
CPT does not have a code that specifically describes total laryngectomy with modified radical neck dissection. The two approaches used in practice are:
Option A: Report 31360 + 38720-59 (cervical lymphadenectomy with modifier -59 for distinct procedural service). This accurately describes the two separate procedures performed. NCCI may bundle 38720 into 31360 — a modifier -59 or --XU is needed to override the edit. Some payers will accept this and pay separately; others will bundle to 31365.
Option B: Report 31365 (total laryngectomy with radical neck dissection) as the single closest available code, even though the neck dissection performed was technically modified radical. This is a less accurate description of the procedure but avoids bundling disputes. The ACS, AAPC, and AAO-HNS have acknowledged this coding gap.
Billing guidance: Discuss with your payers in advance. Document the exact levels and structures preserved/removed in the operative note to support whichever approach is used. Do NOT upcode a standard MRND to a radical neck dissection simply to use 31365 without documentation supporting it.
What Is Included in CPT 31360
All of the following are bundled into 31360 and must NOT be separately billed:
- Complete en bloc excision of the larynx (epiglottis, thyroid cartilage, cricoid, arytenoids, vocal folds, subglottis).
- Hyoid bone removal when performed as part of the standard oncologic dissection.
- Separation of the laryngopharynx from the hypopharynx and closure of the pharyngeal defect (pharyngoplasty/pharyngeal repair as part of the resection closure).
- Mobilization and division of the trachea.
- Construction and maturation of the permanent end tracheostoma — suturing tracheal mucosa to neck skin.
- Wound closure including layered closure of the neck.
- Standard drain placement (e.g., Jackson-Pratt or Blake drain).
- All routine post-operative E/M visits within the 90-day global period.
- Suture and drain removal.
- Routine stoma care instruction.
What Is NOT Included — Separately Reportable
| Service | CPT | Notes |
|---|---|---|
| Tracheoesophageal puncture (TEP) for voice prosthesis — primary | 31611-51 | Most commonly performed at time of laryngectomy — separately reportable with modifier -51; see TEP section |
| Modified radical neck dissection | 38720-59 | When MRND performed with 31360 — modifier -59 required to override NCCI bundle; payer acceptance varies |
| Selective neck dissection | 38720-59 | Selective dissection (levels II-IV or central neck) similarly requires -59 |
| Radical neck dissection | Use 31365 instead | When formal RND (SCM + IJV + CN XI sacrifice) performed — code the entire procedure as 31365, not 31360 + 38724 |
| Bilateral neck dissection | 38720-50-59 | Bilateral selective or MRND — modifier -50 for bilateral; -59 for unbundling from 31360 |
| Partial or total thyroidectomy | 60220 or 60240-51-59 | When thyroid lobe or total thyroid separately resected — document as distinct from the standard strap muscle and thyroid isthmus mobilization included in laryngectomy |
| Pectoralis major myocutaneous flap | 15734-51 | Rotational flap for pharyngeal reconstruction — separately reportable when required for closure of large pharyngeal defect |
| Free flap reconstruction | 43116 or appropriate free flap code with -51 | Jejunal or radial forearm free flap for pharyngoesophageal reconstruction — separately reportable; co-surgeon (-62) often applies |
| Tracheobronchoscopy at time of laryngectomy | 31615 | Bronchoscopy through established tracheostomy incision — may be separately reportable if separately documented with distinct indication |
| Esophagoscopy or pharyngoscopy | 43191 or 43200 | If esophagus separately evaluated — separately reportable with modifier -59 |
| Feeding tube placement (G-tube or NGT) | 43246 or 43760 | Separately reportable when placed at same operative session |
| Postoperative speech pathology and rehabilitation | 92507/92508 | Billed by SLP independently — not part of surgeon’s global package |
| Second surgeon (co-surgeon for free flap) | -62 modifier on free flap code | Two primary surgeons performing distinct portions of the procedure simultaneously |
Tracheoesophageal Puncture (TEP) — CPT 31611
CPT 31611 (Construction of tracheoesophageal fistula and subsequent insertion of alaryngeal speech prosthesis) is the most commonly added procedure at the time of total laryngectomy (31360):
| TEP Timing | Coding Approach |
|---|---|
| Primary TEP — TEP placed at time of laryngectomy (same operative session) | Report 31360 + 31611-51 — modifier -51 for multiple procedures; separately reportable |
| Secondary TEP — TEP placed at a separate, later procedure | Report 31611 alone on the date of the secondary procedure |
Primary TEP documentation requirements:
- Document that the tracheoesophageal puncture was created as a distinct, intentional step.
- Document placement of the voice prosthesis (Blom-Singer, Provox, InHealth, etc.) or indwelling catheter if prosthesis not immediately inserted.
- Note the size and type of prosthesis placed.
- Primary TEP is performed by creating a small fistula through the posterior tracheal wall into the esophagus at the time of laryngectomy, before closing the tracheostoma.
Key coding note: Do NOT separately bill tracheostoma creation as a separate procedure — the tracheostoma is created as part of 31360. The TEP (31611) is the additional distinct procedure, not the stoma.
Salvage Laryngectomy — Special Considerations
Salvage total laryngectomy refers to laryngectomy performed after failure of organ-preservation treatment (radiation, chemoradiation, or prior partial laryngectomy). It is one of the most technically demanding procedures in head and neck surgery:
- Dense fibrosis and radiation-induced tissue changes obliterate normal tissue planes.
- Pharyngeal closure is much more tenuous — risk of pharyngocutaneous fistula is significantly elevated (estimated 20-40% in salvage cases vs. 5-10% primary).
- Flap reconstruction (pectoralis major myocutaneous flap or free flap) is more commonly required.
- Wound healing complications are markedly higher.
CPT coding for salvage laryngectomy:
- Report 31360 (or 31365 if RND is performed) — there is no separate CPT code for “salvage” laryngectomy.
- Modifier -22 (significantly increased procedural services) is strongly supported and recommended when:
- Extensive fibrosis from prior radiation documented in operative note.
- Significantly prolonged operative time documented.
- Major reconstruction required due to tissue friability and healing compromise.
- Flap coverage required (separately reportable, but -22 may also apply to 31360 itself).
- The operative report must explicitly describe the radiation-related tissue changes, the nature and extent of the increased complexity, and the total operative time to support modifier -22.
Pharyngocutaneous Fistula — Post-Op Complication Coding
Pharyngocutaneous fistula (PCF) is the most feared and common major complication after total laryngectomy, occurring in 5-40% of cases depending on prior radiation status:
| Scenario | CPT | ICD-10-CM |
|---|---|---|
| PCF managed conservatively (wound care, NPO, feeding tube) | No surgical CPT during global period — included in post-op global package | T81.89xA — Other complications of procedures; or J95.02 — Post-procedure fistula |
| PCF requiring return to OR for debridement and reclosure | 31360-78 (return to OR for complication within global period) | T81.89xA |
| PCF requiring flap repair outside global period | Appropriate flap CPT | J95.09 or T81.89XA |
Modifier -78 is critical when PCF or any other complication requires return to the OR within the 90-day global period of 31360.
wRVU and Reimbursement
| Year | wRVU |
|---|---|
| 2025 | ~26.76 |
| 2026 | ~26.35 |
CPT 31365 (with radical neck dissection) carries higher wRVU (~29.50 in 2026) reflecting the additional complexity of the neck dissection component. Verify exact values against the CMS MPFS Final Rule for CY2026 published November 2025.
Global Period
- Global period: 090 (90-day global package)
- Includes:
- Pre-operative visit one day before surgery.
- All intraoperative services.
- All routine post-operative follow-up within 90 days.
- Stoma care education and routine management.
- Drain and suture removal.
- Routine management of surgical complications not requiring return to OR.
- Outside the global (separately billable):
- Unrelated conditions — modifier -24.
- Return to OR for complications — modifier -78 (pharyngocutaneous fistula requiring OR, hemorrhage, flap failure).
- Planned staged procedures — modifier -58 (planned delayed flap revision, planned secondary TEP placement).
- Unrelated surgical procedure — modifier -79.
- Speech pathology services — billed by SLP; not in the surgeon’s global.
Assistant at Surgery
- Payable: Yes — CPT 31360 is a major complex oncologic procedure for which assistant-at-surgery is payable under Medicare MPFS.
- Modifiers:
- -80 — MD/DO surgical assistant.
- -82 — MD assistant when qualified resident unavailable.
- -AS — PA/NP/CNS first assist.
- -62 — Two primary surgeons (co-surgeons) when a second primary surgeon performs a distinct portion of the procedure requiring different surgical skills — most commonly when a microvascular free flap surgeon simultaneously performs vessel preparation and anastomosis.
- Document the assistant’s role in the operative note.
HCC / Risk Adjustment
CPT codes do not carry HCC mapping. HCC weight flows from the ICD-10-CM diagnosis:
| ICD-10-CM | Description | HCC |
|---|---|---|
| C32.0 | Malignant neoplasm of glottis | HCC 10 |
| C32.1 | Malignant neoplasm of supraglottis | HCC 10 |
| C32.2 | Malignant neoplasm of subglottis | HCC 10 |
| C32.3 | Malignant neoplasm of laryngeal cartilage | HCC 10 |
| C32.8 | Malignant neoplasm of overlapping sites of larynx | HCC 10 |
| C32.9 | Malignant neoplasm of larynx, unspecified | HCC 10 |
| C77.0 | Secondary malignant neoplasm of lymph nodes of head, face and neck | HCC 10/11 |
| C79.89 | Secondary malignant neoplasm of other specified sites | HCC 10/11 |
| Z85.21 | Personal history of malignant neoplasm of larynx | No HCC — historical |
Document all comorbidities (CKD, diabetes, COPD, malnutrition, prior radiation effects) to capture CC/MCC weight for DRG optimization.
MS-DRG
CPT 31360 groups under MDC 03 — Diseases and Disorders of the Ear, Nose, Mouth and Throat when laryngeal malignancy is the principal diagnosis:
| DRG | Description | When |
|---|---|---|
| 129 | Major Head and Neck Procedures with MCC | Laryngectomy + MCC documented — highest reimbursement |
| 130 | Major Head and Neck Procedures with CC | Laryngectomy + CC documented |
| 131 | Major Head and Neck Procedures without CC/MCC | Laryngectomy, no CC/MCC documented |
DRG 129 vs. 131 reimbursement differential is substantial — the difference between a DRG 129 and DRG 131 assignment can represent 15,000 in hospital reimbursement per case depending on the base rate.
Common CC/MCC documentation opportunities for laryngectomy patients:
| Condition | ICD-10-CM | CC or MCC |
|---|---|---|
| Severe protein-calorie malnutrition | E43 | MCC |
| Moderate malnutrition | E44.0 | CC |
| COPD exacerbation | J44.1 | MCC |
| Respiratory failure, acute | J96.01 | MCC |
| Sepsis (post-op) | A41.9 | MCC |
| Encephalopathy (toxic/metabolic) | G92.9 | MCC |
| Pneumonia | J18.9 | CC |
| Dehydration | E86.0 | CC |
| Type 2 diabetes with complication | E11.649 | CC |
| CKD Stage 4 | N18.4 | CC |
| Alcohol dependence | F10.20 | CC |
| Tobacco use disorder | F17.210 | Not CC/MCC but relevant to risk stratification |
| Anemia due to chronic disease | D63.0 | CC |
| Post-radiation fibrosis | M35.00 | CC |
| Pharyngocutaneous fistula (post-op) | J95.02 | CC |
CDI note: Laryngectomy patients are almost universally malnourished, often have severe COPD from tobacco use history, and frequently have post-radiation complications — complete comorbidity documentation is a high-yield CDI opportunity for every laryngectomy admission.
Common ICD-10-CM Diagnoses Paired with CPT 31360
Primary Malignant Laryngeal Diagnoses
| ICD-10-CM | Description |
|---|---|
| C32.0 | Malignant neoplasm of glottis (true vocal cords — most common) |
| C32.1 | Malignant neoplasm of supraglottis (epiglottis, aryepiglottic folds, false cords) |
| C32.2 | Malignant neoplasm of subglottis |
| C32.3 | Malignant neoplasm of laryngeal cartilage |
| C32.8 | Malignant neoplasm of overlapping sites of larynx |
| C32.9 | Malignant neoplasm of larynx, unspecified |
Nodal and Metastatic Disease (commonly coded alongside)
| ICD-10-CM | Description |
|---|---|
| C77.0 | Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck (clinical N+ disease) |
| C78.30 | Secondary malignant neoplasm of unspecified respiratory organ (distant spread — if applicable) |
Histologic Variants (less common but important)
| ICD-10-CM | Description |
|---|---|
| C32.0 | SCC of glottis (most common histology) |
| D02.0 | Carcinoma in situ of larynx (T0/Tis — rare indication for total laryngectomy) |
| C32.9 | Verrucous carcinoma, chondrosarcoma, adenocarcinoma of larynx — use C32.x with pathology specificity |
Non-Oncologic Indications
| ICD-10-CM | Description |
|---|---|
| J69.0 | Pneumonitis due to inhalation of food and vomit (chronic aspiration — non-oncologic laryngectomy) |
| J38.6 | Stenosis of larynx (failed reconstruction, ventilator-dependent) |
| M87.38 | Osteonecrosis due to previous trauma — other bone (chondroradionecrosis) |
| L89.xx | Pressure ulcer — post-radiation laryngeal/pharyngeal necrosis variant coding |
Coding Examples
Example 1 — T3N0M0 Glottic SCC, Total Laryngectomy with Primary TEP
Scenario 68-year-old male with T3N0M0 squamous cell carcinoma of the glottis, failed organ preservation candidacy due to cartilage invasion. Undergoes total laryngectomy without neck dissection. At the time of laryngectomy, a primary tracheoesophageal puncture is created and an indwelling voice prosthesis (Provox Vega 20Fr) is placed. A pectoralis major myocutaneous flap is not required — primary pharyngeal closure achieved.
CPT
- 31360 — Laryngectomy, total, without radical neck dissection.
- 31611-51 — Construction of tracheoesophageal fistula and insertion of alaryngeal speech prosthesis (TEP); modifier -51 for multiple procedures performed at same session.
- 31360-80 (or -AS) — If assistant surgeon present.
ICD-10-CM
- C32.0 — Malignant neoplasm of glottis (primary diagnosis).
MS-DRG
- DRG 129 (with MCC) / 130 (with CC) / 131 (no CC/MCC) — document all comorbidities.
Coding note: TEP (31611) is separately reportable with modifier -51 — it is NOT bundled into 31360. The voice prosthesis device itself is not separately billable as a supply under the physician fee schedule — it is typically included in the non-facility PE RVU. Inpatient hospital may bill separately for device costs under pass-through or device offset categories.
Example 2 — T4a Supraglottic SCC with Clinical N1, Total Laryngectomy + Selective Neck Dissection
Scenario 61-year-old with T4a N1 squamous cell carcinoma of the supraglottis with thyroid cartilage invasion. Total laryngectomy performed. A right selective neck dissection (Levels II-IV) is performed for the clinically positive Level II node. Left neck — cN0 — is not dissected. No formal radical neck dissection (SCM, IJV, and CN XI preserved).
CPT
- 31360 — Laryngectomy, total, without radical neck dissection.
- 38720-59-RT — Cervical lymphadenectomy (selective neck dissection, right, Levels II-IV); modifier -59 to override NCCI edit bundling 38720 into 31360; modifier -RT for right laterality.
- 31611-51 — TEP at time of laryngectomy (if performed).
- 31360-80 — Surgical assistant.
ICD-10-CM
- C32.1 — Malignant neoplasm of supraglottis.
- C77.0 — Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck (N1 nodal disease confirmed).
Coding note: NCCI bundles 38720 into 31360 — modifier -59 (or -XU) is required to unbundle and bill both. Some payers will accept this combination; others will roll it into 31365. Know your payer behavior. The operative note must explicitly describe the selective neck dissection levels dissected, structures preserved, and lymph node count to support the unbundled claim.
Example 3 — T4a Glottic SCC with cN2, Total Laryngectomy with Bilateral MRND
Scenario 72-year-old with T4a N2c glottic SCC. Total laryngectomy with bilateral modified radical neck dissections (Levels I-V bilaterally, preserving SCM, IJV, and CN XI on both sides) performed. No TEP at this session — patient to have secondary TEP at 6-8 weeks.
CPT
- 31360 — Laryngectomy, total, without radical neck dissection.
- 38720-50-59 — Bilateral cervical lymphadenectomy (modified radical neck dissection); modifier -50 for bilateral; modifier -59 to override NCCI bundle with 31360.
- 31360-80 — Surgical assistant.
ICD-10-CM
- C32.0 — Malignant neoplasm of glottis.
- C77.0 — Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck (N2c bilateral nodal disease).
Coding note (MRND billing nuance): As discussed in the code selection section, some coders and facilities prefer to report 31365 + 38720-50-59 (right and left MRND) or report 31365 alone for bilateral total laryngectomy with bilateral neck dissections. Discuss with payer in advance. Document bilateral dissection levels explicitly in the operative report.
Example 4 — Salvage Laryngectomy, Modifier -22, Post-Chemoradiation
Scenario 66-year-old with recurrent T3N0 glottic SCC following definitive chemoradiation (70 Gy) 18 months prior. Salvage total laryngectomy performed. Operative note documents extensive radiation fibrosis, obliterated tissue planes in the pre-epiglottic and paraglottic spaces, dense adhesion of larynx to carotid sheath, prolonged operative time of 7.5 hours (vs. standard 3-4 hours for primary laryngectomy), and requirement for pectoralis major myocutaneous flap for pharyngeal closure due to tissue friability.
CPT
- 31360-22 — Laryngectomy, total, without radical neck dissection; modifier -22 for significantly increased procedural services (salvage setting, radiation fibrosis, extended operative time, mandatory flap reconstruction; attach operative note and supporting documentation).
- 15734-51 — Muscle, myocutaneous, or fasciocutaneous flap; trunk (pectoralis major PMMC flap for pharyngeal closure); separately reportable.
- 31611-51 — TEP at time of laryngectomy (if performed).
- 31360-62 — Co-surgeon (if reconstructive surgeon simultaneously performs vessel work or two-team approach).
ICD-10-CM
- C32.0 — Malignant neoplasm of glottis (recurrent).
- Z85.21 — Personal history of malignant neoplasm of larynx (prior treated primary — for context; the current encounter is the active malignancy).
- Z79.899 — Long-term drug use (prior chemotherapy context).
Coding note: Modifier -22 claims require a cover letter, operative note, and supporting documentation of the increased complexity submitted with the claim. Expect payer medical review; reimbursement adjustment is typically 20-30% above the standard fee when well-documented. The PMMC flap (15734) is separately reportable and not bundled into 31360 or 31360-22.
Example 5 — Secondary TEP Placement, Separate Encounter
Scenario Same patient from Example 1, now 8 weeks post-laryngectomy. Returns to OR as an outpatient for secondary tracheoesophageal puncture and voice prosthesis insertion (primary TEP was not placed at time of laryngectomy in this scenario — pharyngeal closure was tenuous and voice prosthesis placement was deferred).
CPT
- 31611 — Construction of tracheoesophageal fistula and subsequent insertion of alaryngeal speech prosthesis (secondary TEP — performed as separate, later procedure).
- Modifier -58 if this was planned at the time of the original laryngectomy and is within the 90-day global period of 31360 (staged, planned procedure — modifier -58 is required to bill 31611 during the global period of 31360).
ICD-10-CM
- C32.0 — Malignant neoplasm of glottis (underlying diagnosis).
- Z93.0 — Tracheostomy status (patient is a laryngectomee — tracheostoma in place).
- R49.1 — Aphonia (inability to speak — drives the medical necessity for TEP placement).
Coding note: If the secondary TEP was planned at the time of the original laryngectomy (documented in the original operative note as “TEP deferred pending healing — to be placed at 6-8 weeks”), modifier -58 is required during the global period. If the need for secondary TEP was not anticipated at the time of laryngectomy and arose independently, modifier -79 may be more appropriate. Document the original plan clearly.
Example 6 — Pharyngocutaneous Fistula Requiring Return to OR
Scenario Same patient from Example 1, day 14 post-laryngectomy. Develops pharyngocutaneous fistula with saliva expressible through anterior neck wound. Conservative management fails; patient returns to OR for wound debridement, fistula takedown, and primary reclosure on day 18.
CPT
- 31360-78 — Laryngectomy procedure code with modifier -78 (unplanned return to OR for management of a complication — pharyngocutaneous fistula — within the 90-day global period of 31360).
ICD-10-CM
- J95.02 — Tracheostomy malfunction (if tracheostoma is involved in the fistula).
- T81.89XA — Other complications of procedures, not elsewhere classified, initial encounter (pharyngocutaneous fistula as a post-procedural complication).
Coding note: Modifier -78 is mandatory for return to OR within the global period for a related complication. Reimbursement for -78 procedures is reduced to the intraoperative component only — the post-operative period of the original 31360 remains in effect and is not restarted by the -78 procedure.
Example 7 — Post-Op Visit, Unrelated Condition During 90-Day Global
Scenario Same patient, day 30 post-laryngectomy. Presents to the surgeon with new-onset atrial fibrillation with rapid ventricular response. The surgeon evaluates, orders cardiac monitoring, and arranges cardiology consultation. This is entirely unrelated to the laryngectomy.
CPT
- 99214-24 — Established patient E/M, moderate complexity; modifier -24 for evaluation and management of an unrelated condition during the 90-day global period of 31360.
ICD-10-CM
- I48.0 — Paroxysmal atrial fibrillation (unrelated to the laryngectomy — supports modifier -24).
Coding note: Without modifier -24, this E/M claim will be automatically denied as bundled into the global period of 31360. The diagnosis code for the unrelated condition (atrial fibrillation, not the laryngeal cancer) is what clinically and administratively supports the -24 modifier.
Key Coding Pearls
- 31360 = total laryngectomy, NO radical neck dissection — the moment a formal radical neck dissection is performed (sacrifice of SCM, IJV, CN XI), the code upgrades to 31365; do not report 31360 + 38724.
- MRND with 31360 = coding gray zone — report 31360 + 38720-59 (preferred for accuracy) or 31365 (simpler for billing); discuss with your payers; document dissection levels and structures preserved in the operative note.
- TEP is always separately reportable — whether primary (31611-51) or secondary (31611); it is never bundled into 31360; always add 31611 when TEP is performed.
- Modifier -22 for salvage laryngectomy — prior radiation significantly elevates complexity; document fibrosis, extended operative time, and reconstruction requirements explicitly; attach the operative note to the -22 claim.
- Flap reconstruction is separately reportable — pectoralis major flap (15734), free flap (jejunum or radial forearm), and other reconstructive procedures are never bundled into 31360; report them separately with modifier -51 or -62.
- Once-in-a-lifetime designation — Medicare considers 31360/31365 once-in-a-lifetime procedures; a second claim will auto-deny; salvage laryngectomy after prior partial laryngectomy requires documentation and may require prior authorization or appeal.
- Inpatient only — 31360 cannot be performed in an outpatient or ASC setting under Medicare; always inpatient hospital.
- 90-day global is strict and long — all related services for 3 months post-op are bundled; SLP services are billed by the SLP, not the surgeon, and are not part of the surgeon’s global; speech therapy is a major post-op resource not restricted by the surgeon’s global package.
- CDI opportunity — malnutrition, COPD, alcohol dependence, radiation fibrosis, and post-op complications are high-yield CC/MCC documentation targets for DRG 129 capture; every point of comorbidity documented accurately can materially affect hospital reimbursement.
- Stoma care — routine tracheostoma care within the global period is bundled; home health visits for stoma care are billed by the home health agency, not the surgeon.
Suggested Obsidian Linkouts
- Otolaryngology CPT Codes Reference
- Global Surgical Package MOC
- Procedure Status & Complexity Modifiers
- -22 - Modifier 22, significantly increased procedural services
- -24 - Modifier 24, unrelated E/M during global period
- -51 - Modifier 51, multiple procedures
- -58 - Modifier 58, staged procedure
- -59 - Modifier 59, distinct procedural service
- -62 - Modifier 62, co-surgeons
- -78 - Modifier 78, unplanned return to OR
- -79 - Modifier 79, unrelated procedure during global period
- -80 - Modifier 80, surgical assistant
- -AS - Modifier AS, PA/NP first assist
- -XU - Modifier XU, unusual non-overlapping service