🔪 CPT 31365 — Laryngectomy; Total, With Radical Neck Dissection
Quick Reference
wRVU: 37.84¹ | Global Period: 090 | Assistant Payable: Yes | Bilateral Indicator: 0 Rule: CPT 31365 carries a bilateral indicator of 0 because the larynx is a single midline structure — a laryngectomy cannot be performed “bilaterally,” so modifier -50 is never appropriate regardless of neck dissection extent².⁴ -RT/-LT identify which side of the neck the dissection occurred on, not the larynx itself². When a contralateral or modified radical neck dissection is also performed, it is reported separately with 38724 and modifier -59, not as a second unit of **31365**².
📋 Clinical Description
CPT 31365 describes complete excision of the larynx performed with a radical neck dissection — removal of ipsilateral cervical lymph node levels I through V along with the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve. This combined approach is reserved for advanced laryngeal carcinoma with documented or high-risk regional nodal metastasis, distinguishing it from 31360 (total laryngectomy without neck dissection).
The procedure causes permanent loss of natural voice and requires a permanent tracheostoma. Compared to 31367 (subtotal supraglottic laryngectomy), which preserves some laryngeal function, 31365 is fully ablative; compared to 31390 (pharyngolaryngectomy with radical neck dissection), 31365 does not include hypopharynx resection.
Clinical contexts:
- Primary treatment for T3-T4 laryngeal squamous cell carcinoma with clinically positive cervical nodes.
- Salvage surgery after failed radiation/chemoradiation with nodal spread.
- Cases with fixed or matted lymphadenopathy meeting radical dissection criteria.
- Severe laryngeal trauma or necrosis with concurrent neck exploration (rare, non-oncologic).
- Recurrent laryngeal cancer after prior partial laryngectomy with new nodal disease.
🔬 Anatomical & Procedural Considerations
| Variant | Mechanism | Key Notes |
|---|---|---|
| Total Laryngectomy Component | The trachea is separated from the larynx, superior laryngeal vessels are ligated, and the entire laryngeal skeleton is removed en bloc, with the airway matured as a permanent tracheostoma. | Voice restoration options are billed separately and not bundled into 31365. |
| Radical Neck Dissection Component | All five ipsilateral cervical lymph node levels are removed en bloc with the SCM, IJV, and spinal accessory nerve. | Sparing any of these structures makes it a modified radical dissection (38724), not 31365. |
| Reconstruction/Closure | Pharyngeal mucosa is closed in layers, sometimes reinforced with a pectoralis major or free flap in irradiated necks. | Flap harvest (15734, 15756) is separately reportable. |
Clinical Pearl
Confirm the operative note explicitly states “radical neck dissection” with removal of the SCM, IJV, and spinal accessory nerve; if any structure is preserved, the correct combination is 31360 plus 38724 rather than 31365 alone².
✅ Procedure Includes
- Complete resection of the laryngeal cartilaginous framework and intrinsic musculature.
- Ligation of superior and inferior laryngeal neurovascular bundles.
- Creation and maturation of a permanent tracheostoma.
- Ipsilateral radical cervical lymphadenectomy of levels I-V.
- Removal of the SCM, IJV, and spinal accessory nerve on the dissected side.
- Primary closure of the pharyngeal defect.
- Placement of surgical drains.
❌ Excludes / Do Not Report Together
| Code | Description | Relationship |
|---|---|---|
| 31360 | Laryngectomy; total, without radical neck dissection | Do not report with 31365 in the same session; choose one based on dissection extent². |
| 38724 | Cervical lymphadenectomy (modified radical neck dissection) | Reported instead of, or alongside with modifier -59, 31365 when the dissection is modified or contralateral². |
| 31367 | Laryngectomy; subtotal supraglottic, without radical neck dissection | Mutually exclusive since only one laryngectomy extent is billed per larynx. |
| 31390 | Pharyngolaryngectomy, with radical neck dissection; without reconstruction | Used instead of 31365 when the hypopharynx is also removed. |
Bundling Alert
The 090-day global period bundles all related postoperative visits, wound checks, and drain management within 90 days. Any subsequent unrelated procedure requires modifier -78 or -79 with clear documentation. Audit risk is high when contralateral neck disease is billed as a duplicate 31365 rather than 38724-59.
🌳 Code Tree — Surgery: Larynx
CPT 31300-31599 Surgery: Larynx
│
├── 31300-31320 Laryngotomy/Laryngostomy
│ ├── 31300 Laryngotomy, with removal of tumor, laryngocele, or web
│ └── 31320 Laryngotomy, diagnostic
│
├── 31360-31382 Excision (Larynx)
│ ├── 31360 Laryngectomy; total, without radical neck dissection
│ ├── ▶▶ 31365 ◀◀ Laryngectomy; total, with radical neck dissection ← YOU ARE HERE (Global: 090)
│ ├── 31367 Laryngectomy; subtotal supraglottic, without radical neck dissection
│ └── 31368 Laryngectomy; subtotal supraglottic, with radical neck dissection
│
└── 31390-31395 Pharyngolaryngectomy
├── 31390 Pharyngolaryngectomy, with radical neck dissection; without reconstruction
└── 31395 Pharyngolaryngectomy, with radical neck dissection; with reconstruction💰 RVU & Reimbursement Profile
| Component | Value |
|---|---|
| Work RVU | 37.84¹ |
| Global Period | 090 |
| Bilateral Indicator | 0 |
| Assistant Surgeon | Payable |
| Co-Surgeon | Payable with documentation |
| Team Surgery | Not typically applicable |
| PC/TC Split | 0 |
| Modifier -51 Exempt | No |
| Anesthesia | General; billed separately |
Bilateral Billing Rules
Modifier -50 should never be appended to 31365 since the larynx is a single unpaired midline organ⁴. For bilateral neck disease, report one unit of 31365 for the laryngectomy plus ipsilateral dissection, and a separate 38724 with modifiers -59 and opposite-side -RT/-LT for the contralateral neck².
🏷️ Modifier Reference
| Modifier | Name | When to Apply |
|---|---|---|
| -RT | Right Side | Indicates the radical neck dissection side; the larynx has no laterality. |
| -LT | Left Side | Indicates dissection side; used for contralateral 38724 reporting. |
| -22 | Increased Procedural Services | For substantially increased complexity, such as a fibrotic or previously irradiated neck. |
| -62 | Two Surgeons | When two surgeons of different specialties each perform a distinct portion. |
| -80 | Assistant Surgeon | When a second physician actively assists throughout. |
| -AS | PA/NP/CNS Assistant at Surgery | When a non-physician practitioner assists instead of a physician. |
🩺 Common ICD‑10‑CM Pairings
Primary Diagnosis Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| C32.0 | Malignant neoplasm of glottis | Yes | Most common primary diagnosis supporting 31365. |
| C32.1 | Malignant neoplasm of supraglottis | Yes | Higher propensity for early nodal metastasis. |
| C32.3 | Malignant neoplasm of laryngeal cartilage | Yes | Often signals advanced T4 disease. |
| C32.8 | Malignant neoplasm of overlapping sites of larynx | Yes | Used when tumor spans multiple subsites. |
| C32.9 | Malignant neoplasm of larynx, unspecified | Yes | Avoid when subsite documentation exists. |
Secondary Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| Z85.21 | Personal history of malignant neoplasm of larynx | No | For follow-up encounters, not the operative claim. |
| Z93.0 | Tracheostomy status | No | For postoperative encounters reflecting the tracheostoma. |
Etiology / Complication
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| R49.0 | Dysphonia | No | May support preoperative medical necessity documentation. |
| J95.00 | Unspecified tracheostomy complication | No | For postoperative complications within the global period. |
Coding Specificity Reminder
Always code to the most specific laryngeal subsite documented rather than defaulting to C32.9. Never use the parent category C32 alone — it is incomplete and not billable.
🏥 MS‑DRG Considerations
Inpatient 31365 typically groups to DRG 129, 130, or 131 (Major Head and Neck Procedures with MCC, with CC, or without CC/MCC) depending on comorbidity capture. Accurate secondary diagnosis capture (malnutrition, aspiration pneumonia, acute respiratory failure) can shift the case to a higher-weighted tier.
🔧 ICD‑10‑PCS Equivalents
| PCS Code | Full Description | Modality |
|---|---|---|
| 0CTS0ZZ | Resection of larynx, open approach | Open surgical resection |
| 0CTS4ZZ | Resection of larynx, percutaneous endoscopic approach | Rarely used for total laryngectomy |
| 07B60ZZ | Excision of right neck lymphatic, open approach | Right-sided lymphadenectomy |
| 07B70ZZ | Excision of left neck lymphatic, open approach | Left-sided lymphadenectomy |
PCS Character Analysis
| Position | Character | Value | Definition |
|---|---|---|---|
| 1 | Section | 0 | Medical and Surgical |
| 2 | Body System | C | Respiratory system |
| 3 | Root Operation | T | Resection — cutting out all of a body part without replacement |
| 4 | Body Part | S | Larynx |
| 5 | Approach | 0 | Open |
| 6 | Device | Z | No device |
| 7 | Qualifier | Z | None needed |
Root Operation Comparison
Resection (T) is used because the entire larynx is removed, unlike Excision (B) for partial removal. The neck dissection is coded separately as Excision (B) of the cervical lymphatic body part. Never combine the laryngectomy and neck dissection into a single PCS code.
📝 Coding Examples
Example 1
Clinical Scenario: A 64-year-old male with T4N2b glottic squamous cell carcinoma undergoes total laryngectomy with ipsilateral right radical neck dissection (levels I-V, SCM, IJV, CN XI removed), primary pharyngeal closure; pathology confirms extracapsular nodal extension.
| Field | Code | Rationale |
|---|---|---|
| CPT | 31365-RT | Captures the combined laryngectomy and radical dissection with side indicated. |
| PDx | C32.0 | Glottic subsite driving the procedure. |
Note
Confirm SCM/IJV/CN XI removal is documented to justify “radical” terminology.
Example 2
Clinical Scenario: A 58-year-old female with recurrent supraglottic carcinoma post chemoradiation undergoes salvage total laryngectomy with left radical neck dissection and right modified radical neck dissection sparing CN XI, plus pectoralis major flap reinforcement.
| Field | Code | Rationale |
|---|---|---|
| CPT 1 | 31365-LT | Laryngectomy bundled with left radical dissection. |
| CPT 2 | 38724-59-RT | Right modified radical dissection reported separately. |
| PDx | C32.1 | Supraglottic subsite. |
Warning
Example 3
Clinical Scenario: A 70-year-old male undergoes total laryngectomy with right radical neck dissection for glottic cancer; three weeks postop, within the global period, he returns to the OR for hematoma evacuation unrelated to malignancy progression, same surgeon.
Global period reminder
⚠ Common Coding Pitfalls
- Appending modifier -50 to 31365, which is never appropriate since the larynx is a single midline structure⁴.
- Billing two units of 31365 for bilateral neck disease instead of 38724-59 for the second side².
- Using 31365 when the note describes a modified (not true radical) dissection — should instead be 31360 plus **38724**².
- Defaulting to unspecified C32.9 when the pathology report documents a specific subsite.
- Failing to append modifier -78 for a related, unplanned return to the OR within the global period.
- Separately billing routine postoperative tracheostoma care or wound checks within the global period.