Crystal's Coder Hub🗣️ CPT 31576 — Laryngoscopy, Flexible; With Biopsy(ies)
Quick Reference
wRVU: Verify current MPFS1 | Global Period: 000 (same day) | Assistant Payable: ❌ No | Bilateral Indicator: 0
📋 Clinical Description
CPT 31576 describes a flexible endoscopic evaluation of the larynx accompanied by a tissue biopsy. The provider inserts a flexible laryngoscope through the patient’s nasal cavity, passing it down to visualize the pharynx, larynx, and vocal cords. Upon identifying suspicious or abnormal tissue, tiny biopsy forceps are passed through the working channel of the endoscope to grasp and remove one or multiple tissue samples. This code is distinct from 31575, which is strictly for a diagnostic visual examination without tissue removal, and from 31578, which describes the complete removal of a lesion rather than diagnostic tissue sampling.
Suspected Laryngeal Neoplasms (such as C32.9) or chronic inflammatory conditions often present symptomatically as persistent hoarseness or dysphagia. Without a pathological examination of the abnormal tissue retrieved via biopsy, a definitive diagnosis and subsequent treatment plan cannot be established.
This procedure may be performed in the following clinical contexts:
- Suspicious Laryngeal Masses — When a previously visualized nodule or mass requires pathological identification to rule out malignancy.
- Chronic Refractory Dysphonia — When persistent hoarseness or voice changes do not respond to conservative management, prompting direct tissue evaluation.
- Vocal Cord Leukoplakia — To sample white plaques on the vocal cords that carry a risk of dysplastic or malignant transformation.
- Laryngeal Granulomas — To confirm the benign nature of inflammatory tissue often resulting from intubation trauma or severe reflux.
🔬 Anatomical & Procedural Considerations
| Modality / Approach | Mechanism | Key Notes |
|---|---|---|
| Flexible Endoscopic Biopsy | A flexible scope is passed transnasally. Biopsy forceps are introduced through the instrument channel to bite and excise small fragments of the target tissue. | Typically performed with the patient awake using topical anesthesia. Requires a therapeutic flexible scope with a working channel, distinct from standard diagnostic-only scopes. |
| Brush Biopsy / Cytology | A small brush is passed through the working channel to abrade the lesion and collect cells. | Less common than forceps core biopsy but still maps to this code as it involves tissue/cell collection for pathology. |
Clinical Pearl
The CPT descriptor explicitly states “biopsy(ies).” This means 31576 is reported only once per operative session, regardless of whether the provider takes one biopsy from a single lesion or five biopsies from different areas of the larynx. Do not attempt to bill multiple units of this code for multiple tissue samples.2
✅ Procedure Includes
- Application of topical anesthesia/vasoconstrictors to the nasal cavity and pharynx
- Insertion of the flexible laryngoscope and full diagnostic evaluation of the upper airway and larynx
- Passage of biopsy forceps or brush through the endoscope channel
- Excision of one or more tissue samples
- Hemostasis control at the biopsy site
- Withdrawal of the endoscope and routine immediate post-procedure observation
- Preparation of the specimen(s) for pathology
❌ Excludes / Do Not Report Together
| Code | Description | Relationship to 31576 |
|---|---|---|
| 31575 | Laryngoscopy, flexible; diagnostic | Mutually exclusive. A diagnostic laryngoscopy is the inherent precursor to the biopsy and is bundled into the surgical procedure. |
| 31578 | Laryngoscopy, flexible; with removal of lesion(s), non-laser | Report only one or the other for the same lesion. If the provider completely removes the lesion, bill 31578. If they only take a sample and leave the lesion behind, bill 31576. |
| 31535 | Laryngoscopy, direct, operative, with biopsy | Mutually exclusive. Code 31535 involves rigid, direct laryngoscopy (typically in the OR under general anesthesia), whereas 31576 utilizes a flexible fiberoptic or distal sensor scope. |
| 31510 | Laryngoscopy, indirect; with biopsy | Mutually exclusive. Code 31510 relies on a laryngeal mirror for visualization rather than an endoscope. |
| E/M codes (992xx) | Office visit, any level | Separately reportable only when modifier -25 is appended to the E/M code, documenting a significant, separately identifiable E/M service beyond the routine pre-procedure assessment and consent. |
Bundling Alert — Global Period is 000, Not 010
The global period for 31576 is 000 (same day). This means if the patient returns to the office three days later to discuss the pathology results and establish a treatment plan, that follow-up visit is separately billable as an established patient E/M without the need for a global modifier.
🌳 Code Tree — Surgery: Respiratory System
CPT 31300-31599 Larynx
│
├── 31572-31579 Endoscopy (Flexible)
│ ├── 31574 Laryngoscopy, flexible; with injection(s) for augmentation... (Global: 000)
│ ├── 31575 Laryngoscopy, flexible; diagnostic (Global: 000)
│ ├── ▶▶ 31576 ◀◀ Laryngoscopy, flexible; with biopsy(ies) ← YOU ARE HERE (Global: 000)
│ ├── 31577 Laryngoscopy, flexible; with removal of foreign body(s) (Global: 000)
│ └── 31578 Laryngoscopy, flexible; with removal of lesion(s), non-laser (Global: 000)
💰 RVU & Reimbursement Profile
| Component | Value |
|---|---|
| Work RVU (wRVU) | Verify against current 2026 CMS MPFS |
| Global Period | 000 (same day) |
| Bilateral Indicator | 0 — The 150% payment adjustment for bilateral procedures does not apply. The larynx is categorized as a single midline structure. |
| Assistant Surgeon | ❌ Not payable |
| Co-Surgeon | ❌ Not applicable |
| Team Surgery | ❌ Not applicable |
| PC/TC Split | ❌ No — procedure code only (Indicator 0) |
| Modifier -51 Exempt | No |
| Anesthesia | Topical or local infiltration; no separate anesthesia billing expected in the office setting. |
Bilateral Billing Rules
CPT 31576 has a bilateral indicator of 0, meaning Medicare and commercial payers will not recognize bilateral modifiers (-50, -RT, -LT) for this code. Even if a provider biopsies the right vocal cord and then the left vocal cord during the same session, it is reported as a single line item of 31576 with no laterality modifiers.
🏷️ Modifier Reference
| Modifier | Name | When to Apply |
|---|---|---|
| -25 | Significant, Separately Identifiable E/M | Applied to the E/M code — not 31576 — when an office visit is performed on the same date; documentation must support a separate, medically necessary evaluation beyond the decision to perform the biopsy. |
| -51 | Multiple Procedures | When 31576 is performed alongside other distinct surgical procedures at the same session; apply to the lower-valued code. |
| -52 | Reduced Services | Procedure partially completed — e.g., scope inserted but patient could not tolerate the biopsy portion; document reason. |
| -53 | Discontinued Procedure | Procedure stopped due to patient safety concern (e.g., sudden severe laryngospasm or epistaxis). |
| -59 | Distinct Procedural Service | When payers inappropriately bundle 31576 with another procedure; must document a distinct, separate anatomic site (e.g., biopsies taken from entirely separate organ systems at the same encounter). |
🩺 Common ICD-10-CM Pairings
Suspicious Findings & Voice Disorders
| ICD-10 Code | Description | HCC? | Clinical Notes |
|---|---|---|---|
| R49.0 | Dysphonia | ❌ No | Primary symptom code when the underlying cause of hoarseness is not yet established prior to pathology. |
| R49.1 | Aphonia | ❌ No | Loss of voice. |
| J38.1 | Vocal cord and false vocal cord polyp | ❌ No | Common benign finding that may be biopsied to rule out dysplasia. |
| J38.2 | Nodules of vocal cords | ❌ No | ”Singer’s nodes” which may require sampling if atypical in appearance. |
| J38.3 | Other diseases of vocal cords | ❌ No | Includes granulomas and leukoplakia of the vocal cords. |
Neoplasms (Pending Pathology)
| ICD-10 Code | Description | HCC? | Clinical Notes |
|---|---|---|---|
| D14.1 | Benign neoplasm of larynx | ❌ No | Use when the provider suspects the mass is benign (e.g., papilloma), but wait for pathology before assigning definitive malignancy codes. |
| C32.9 | Malignant neoplasm of larynx, unspecified | ✅ HCC 17 | Do not use unless malignancy is already confirmed pathologically or the patient is coming in for a repeat biopsy of known cancer. Do not code “suspected” cancer. |
| D38.0 | Neoplasm of uncertain behavior of larynx | ❌ No | Assigned when previous pathology was inconclusive, prompting a repeat biopsy. |
Coding Specificity Reminder
A common audit trigger in this area is coding a definitive malignancy (like C32.9) on the biopsy claim before the pathology report has finalized. Always code the documented symptom (e.g., R49.0 Dysphonia) or the visual finding (e.g., J38.3 Leukoplakia) as the primary diagnosis for the biopsy encounter itself.
🏥 MS-DRG Considerations (Inpatient)
Inpatient Coding Reminder
CPT 31576 is performed primarily in the outpatient / office / ASC setting. There are no routine MS-DRG assignments for this procedure — inpatient admission for an isolated flexible laryngoscopy with biopsy would not be supported by any payer, MAC, or utilization review body. If a patient undergoing an inpatient admission for an unrelated diagnosis also has a laryngeal biopsy performed, an ICD-10-PCS code may be assigned for completeness, but it will have no meaningful impact on DRG grouping.
🔧 ICD-10-PCS Equivalents (Inpatient Facility Coding)
Note
PCS codes for this procedure belong to the Medical and Surgical section (0). The root operation is always Excision (B) because a portion of the body part is cut out or off. The qualifier is always Diagnostic (X) because the tissue is being sent for pathology.
| PCS Code | Full Description | Applicable Modality |
|---|---|---|
0BBC8ZX | Excision of Larynx, Via Natural or Artificial Opening Endoscopic, Diagnostic | Biopsy of general laryngeal structures |
0BBV8ZX | Excision of Vocal Cord, Via Natural or Artificial Opening Endoscopic, Diagnostic | Biopsy specifically targeting the true vocal cords |
PCS Character Analysis — 0BBC8ZX
| Position | Character | Value | Definition |
|---|---|---|---|
| 1 | Section | 0 | Medical and Surgical |
| 2 | Body System | B | Respiratory System |
| 3 | Root Operation | B | Excision (cutting out or off, without replacement, a portion of a body part) |
| 4 | Body Part | C | Larynx |
| 5 | Approach | 8 | Via Natural or Artificial Opening Endoscopic (Flexible Scope) |
| 6 | Device | Z | No Device |
| 7 | Qualifier | X | Diagnostic (used for biopsies) |
PCS Root Operation: Excision vs. Destruction
- Use Excision (B) for biopsies where tissue is physically removed and preserved for pathological examination.
- Use Destruction (5) if the provider uses a laser or electrocautery through the scope to eradicate the lesion without sending a viable sample to pathology (which would map to CPT 31572, not 31576).
📝 Coding Examples
Example 1 — Office: Flexible Laryngoscopy with Biopsy for Hoarseness
Clinical Scenario: A 62-year-old male with a 40-pack-year smoking history presents with worsening hoarseness over the past two months. After spraying the nasal passages with topical lidocaine, the ENT inserts a flexible fiberoptic laryngoscope transnasally. Examination reveals a rough, white, exophytic plaque (leukoplakia) on the right true vocal cord. The provider passes flexible biopsy forceps through the working channel and takes three small tissue bites of the plaque. Hemostasis is achieved naturally. The specimens are sent to pathology.
| Field | Code | Rationale |
|---|---|---|
| CPT | 31576 | Laryngoscopy, flexible; with biopsy. Reported as a single unit despite three tissue bites being taken. |
| PDx | J38.3 | Other diseases of vocal cords (captures the visual finding of leukoplakia). |
| SDx | R49.0 | Dysphonia (hoarseness symptom). |
Note
Example 2 — Office: Biopsy with a Separately Identifiable E/M
Clinical Scenario: A 55-year-old female presents for a follow-up of her chronic allergic rhinitis and sinusitis, managed with nasal steroids. During the detailed evaluation of her sinus symptoms, she mentions that she has also felt a new “lump in her throat” (globus sensation) for the past two weeks. The provider performs a full E/M assessing the rhinitis and documenting an updated treatment plan. The provider then determines a flexible laryngoscopy is needed to investigate the new globus symptom. The scope reveals a distinct mass on the arytenoid cartilage. The provider takes a biopsy of the mass through the endoscope.
| Field | Code | Rationale |
|---|---|---|
| CPT 1 | 99214-25 | A significant, separately identifiable evaluation was performed and documented for the chronic sinusitis management. |
| CPT 2 | 31576 | Flexible laryngoscopy with biopsy of the new laryngeal mass. |
| PDx | J30.9 | Allergic rhinitis, unspecified (linked to the E/M code). |
| SDx | R09.89 | Other specified symptoms and signs involving the circulatory and respiratory systems (used for globus sensation, linked to the procedure). |
Warning
The -25 modifier is placed on the E/M code, not the procedure code. The documentation clearly shows two distinct tracks of medical decision making: managing the pre-existing rhinitis and addressing the entirely new symptom that led to the biopsy.
⚠️ Common Coding Pitfalls
- Billing multiple units for multiple biopsies: The CPT descriptor explicitly includes the plural “(ies)“. Billing 31576 x 2 or 31576 x 3 because the provider took multiple samples from the larynx is a definitive compliance error that will lead to claim denials and potential recoupments.
- Reporting a diagnostic scope (31575) alongside 31576: NCCI edits strictly prohibit billing a diagnostic flexible laryngoscopy on the same day as a flexible laryngoscopy with biopsy by the same provider. The diagnostic evaluation is considered the required first step of the biopsy procedure and is fully bundled.
- Confusing flexible endoscopy with rigid direct laryngoscopy: If the operative note indicates the patient was in the OR, placed in suspension, and a rigid, straight laryngoscope (like a Kleinsasser or Dedo) was used, the correct code is 31535 or 31536, not 31576. 31576 requires a flexible instrument.
- Confusing a biopsy with lesion removal: If the provider’s documentation states they used the forceps to completely remove a laryngeal polyp, ensuring no residual disease remained, the correct code is 31578 (Laryngoscopy, flexible; with removal of lesion), which carries higher wRVUs. Code 31576 is strictly for tissue sampling.
- Coding unconfirmed malignancies: Avoid assigning cancer codes (e.g., C32.9) on the claim for the biopsy encounter itself based solely on the physician’s visual suspicion. Wait for the pathology report to finalize, or code the patient’s presenting signs/symptoms on the surgical claim to ensure audit-proof documentation.
📎 Sources
1 CMS 2026 Medicare Physician Fee Schedule Final Rule
2 AMA CPT 2026 Professional Edition
3 NCCI Policy Manual for Medicare Services, Chapter 5 (Respiratory System), 2026
4 ICD-10-CM Official Guidelines for Coding and Reporting FY2026
5 ICD-10-PCS Official Guidelines for Coding and Reporting FY2026