🗣️ CPT 31368 — Laryngectomy; Subtotal Supraglottic, With Radical Neck Dissection
Quick Reference
wRVU: 30.61 | Global Period: 090 | Assistant Payable: Yes | Bilateral Indicator: 0
Rule: This code carries a bilateral indicator of 0, meaning the 150% bilateral payment adjustment does not apply because the larynx is a midline, singular structure. Assistant surgeons are permitted and payable when supported by medical necessity.
📋 Clinical Description
CPT 31368 describes a supraglottic laryngectomy, which involves the complex surgical excision of the upper portion of the larynx (above the true vocal cords). This comprehensive procedure specifically includes a radical neck dissection to aggressively remove regional cervical lymph nodes and surrounding affected tissues. The primary clinical goal is to effectively eradicate malignant neoplasms located in the supraglottis while meticulously preserving the true vocal cords, which allows the patient to retain vital phonation and swallowing functions.
This procedure is distinguished from its sibling code, CPT 31367, which represents a subtotal supraglottic laryngectomy without the concurrent radical neck dissection. Another related code, CPT 31370, describes a horizontal partial hemilaryngectomy, also lacking the neck dissection component. Surgeons specifically choose CPT 31368 when regional lymph node metastasis is clinically present or highly suspected, making the extensive neck dissection a medically necessary extension of the primary tumor excision.
This procedure may be performed in the following clinical contexts:
- Malignant Neoplasm of the Supraglottis — Employed when a primary tumor is localized to the epiglottis, false vocal cords, or aryepiglottic folds.
- Regional Lymph Node Metastasis — Indicated when preoperative imaging or biopsies confirm that laryngeal cancer has metastasized to the cervical lymph nodes.
- Voice Preservation Strategy — Chosen for patients with appropriate tumor staging to successfully avoid a total laryngectomy and preserve natural speech capabilities.
- Comprehensive Head and Neck Oncology — Utilized as a critical component of an integrated oncological treatment plan, often coordinated with radiation therapy.
- Recurrent Localized Disease — Performed as salvage surgery in cases of localized laryngeal recurrence following previous limited resections or failed radiation therapy.
🔬 Anatomical & Procedural Considerations
| Variant | Mechanism | Key Notes |
|---|---|---|
| Supraglottic Resection | En bloc surgical excision of the epiglottis, false vocal cords, and pre-epiglottic space through an open anterior neck incision. | The true vocal cords and arytenoids are meticulously spared to maintain airway protection and natural voice generation. |
| Ipsilateral Neck Disease | Radical neck dissection performed on the same side as the predominant laryngeal tumor burden. | This component involves the extensive clearance of lymph nodes from levels I-V, internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve. |
| Bilateral Neck Disease | Requires an additional modified or radical neck dissection on the contralateral side to achieve complete margins. | Modifier -59 and laterality modifiers must be appended to a separate CPT code (e.g., 38724) for the contralateral side, as 31368 only covers the ipsilateral neck dissection. |
Clinical Pearl
Because the larynx is an unpaired, midline organ, the primary laryngectomy procedure is singular. However, the comprehensive nature of the radical neck dissection component mandates careful review of the operative report; if the surgeon crosses over to perform a separate dissection on the contralateral neck, an additional unbundled neck dissection code is warranted to capture the full scope of work.
✅ Procedure Includes
- Initial surgical incision and approach through the anterior neck tissues to expose the laryngeal framework.
- Anatomical dissection and en bloc removal of the upper larynx structures, including the epiglottis and false vocal cords.
- Comprehensive radical neck dissection encompassing the removal of cervical lymph nodes, sternocleidomastoid muscle, and internal jugular vein.
- Complex reconstruction of the upper airway and primary or flap closure of the resulting pharyngeal defect.
- Placement of surgical drains to mitigate the risk of postoperative hematoma and seroma accumulation.
- Routine immediate postoperative hemodynamic monitoring and specialized wound care management.
❌ Excludes / Do Not Report Together
| Code | Description | Relationship |
|---|---|---|
| 31367 | Laryngectomy; subtotal supraglottic, without radical neck dissection | Mutually exclusive, as 31368 inherently includes the extensive radical neck dissection component. |
| 31370 | Partial laryngectomy (hemilaryngectomy); horizontal | Represents a distinctly different anatomical resection approach and scope within the larynx. |
| 31390 | Pharyngolaryngectomy, with radical neck dissection; without reconstruction | Involves the total, destructive removal of both the larynx and pharynx, constituting a more extensive surgery. |
| 38720 | Cervical lymphadenectomy (complete) | The radical neck dissection is inclusively bundled into 31368 and must not be billed separately for the ipsilateral side. |
Bundling Alert
CPT 31368 carries a comprehensive 90-day global period, meaning all routine preoperative, intraoperative, and post-discharge surgical care is bundled into the single reimbursement for this code. The radical neck dissection is strictly inclusive; attempting to code a separate neck dissection on the ipsilateral side constitutes unbundling and poses a severe audit risk. Utilize modifier -59 or -X{E, S, P, U} only if a distinctly separate procedure is performed on an entirely different anatomical site, such as a contralateral neck dissection.
🌳 Code Tree — Surgery: Respiratory System
CPT 31360-31599 Surgery: Respiratory System, Larynx
│
├── 31360-31420 Excision Procedures on the Larynx
│ ├── 31360 Laryngectomy; total, without radical neck dissection (Global: 090)
│ ├── 31365 Laryngectomy; total, with radical neck dissection (Global: 090)
│ ├── 31367 Laryngectomy; subtotal supraglottic, without radical neck dissection (Global: 090)
│ ├── ▶▶ 31368 ◀◀ Laryngectomy; subtotal supraglottic, with radical neck dissection ← YOU ARE HERE (Global: 090)
│ ├── 31370 Partial laryngectomy (hemilaryngectomy); horizontal (Global: 090)
│ └── 31375 Partial laryngectomy (hemilaryngectomy); laterovertical (Global: 090)💰 RVU & Reimbursement Profile
| Component | Value |
|---|---|
| Work RVU | 30.61 |
| Global Period | 090 |
| Bilateral Indicator | 0 |
| Assistant Surgeon | 2 (Permitted) |
| Co‑Surgeon | 1 (Sometimes permitted) |
| Team Surgery | 0 (Not permitted) |
| PC/TC Split | 0 (Not applicable) |
| Modifier -51 Exempt | No |
| Anesthesia | 00320 (Base Units: 6) |
Bilateral Billing Rules
CPT 31368 has a bilateral indicator of “0,” meaning the 150% payment adjustment for bilateral procedures is completely inapplicable. The larynx is a singular, midline structure, making bilateral performance of the primary laryngectomy anatomically impossible. If bilateral radical neck dissections are required, the primary code 31368 covers the larynx and the ipsilateral neck dissection. The contralateral neck dissection must be reported using an additional, distinct CPT code (such as 38720) appended with modifier -59 and the appropriate laterality modifier (-LT/-RT) to signify the separate anatomical side.
🏷️ Modifier Reference
| Modifier | Name | When to Apply |
|---|---|---|
| -22 | Increased Procedural Services | Apply when the laryngeal resection or neck dissection requires substantially greater effort due to severe post-radiation scarring. |
| -52 | Reduced Services | Apply if a portion of the planned supraglottic resection or the radical neck dissection is intentionally aborted. |
| -53 | Discontinued | Apply if the surgery is halted entirely after anesthesia induction due to unexpected patient hemodynamic instability. |
| -58 | Staged | Apply if the procedure was planned prospectively as a subsequent surgical stage during an existing global period. |
| -59 | Distinct Service | Apply when performing a non-bundled, separate procedure on a distinct anatomical site (e.g., contralateral neck dissection). |
| -78 | Return to OR | Apply if the patient requires an unplanned return to the operating room for a post-surgical complication like hemorrhage. |
| -79 | Unrelated Procedure | Apply if an entirely distinct and unrelated surgery is performed by the same physician during the 90-day global period. |
| -80 | Assistant Surgeon | Apply if a second qualified physician directly assists the primary surgeon with the extensive tissue resection and dissection. |
| -82 | Assistant Surgeon (No Resident) | Apply in teaching facilities when a qualified surgical resident is unavailable to assist with the procedure. |
(Note: Modifiers -RT, -LT, -50, -24, and -51 generally do not apply to the base code or are restricted due to the midline nature of the primary organ and specific global edit rules).
🩺 Common ICD‑10‑CM Pairings
Primary Diagnosis Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| C32.1 | Malignant neoplasm of supraglottis | Yes | Describes the exact primary indication and anatomical location necessitating a supraglottic laryngectomy. |
| C32.8 | Malignant neoplasm of overlapping sites of larynx | Yes | Used appropriately when the tumor extends beyond the strict boundaries of the supraglottis into adjacent regions. |
| C32.9 | Malignant neoplasm of larynx, unspecified | Yes | Should be used strictly as a last resort when the explicit laryngeal subsite is entirely absent from documentation. |
| C77.0 | Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck | Yes | Crucial secondary diagnosis that directly justifies the medical necessity of the radical neck dissection component. |
| D02.0 | Carcinoma in situ of larynx | Yes | Used for advanced, high-grade pre-invasive disease requiring definitive surgical resection to prevent progression. |
Secondary Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| Z85.810 | Personal history of malignant neoplasm of tongue | No | Provides important historical context if the patient has a complex prior history of head and neck malignancies. |
| Z87.891 | Personal history of nicotine dependence | No | Highlights a deeply relevant past etiology commonly linked to the development of laryngeal carcinomas. |
Etiology / Complication
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| F17.210 | Nicotine dependence, cigarettes, uncomplicated | No | Represents an active, direct risk factor and common comorbidity complicating postoperative recovery and wound healing. |
| F10.20 | Alcohol use disorder, mild, uncomplicated | Yes | Often represents a highly synergistic risk factor with tobacco use for the genesis of squamous cell carcinomas of the larynx. |
Coding Specificity Reminder
Always sequence the malignant neoplasm to the highest possible degree of specificity, pinpointing the exact anatomical subsite of the larynx (e.g., supraglottis). Additionally, it is absolutely critical to report secondary codes for any regional lymph node metastasis (such as C77.0), as this specifically validates the medical necessity and clinical justification for the radical neck dissection bundle included in CPT 31368.
🏥 MS‑DRG Considerations
Inpatient admissions for CPT 31368 typically route to MS-DRG 129, 130, or 131 (Major Head and Neck Procedures), which are heavily tiered based on the concurrent presence of Major Complications and Comorbidities (MCC) or Complications and Comorbidities (CC). If a therapeutic or prophylactic tracheostomy is performed concurrently—which is common for airway protection in these extensive resections—the entire case may definitively map to MS-DRG 011, 012, or 013 (Tracheostomy for Face, Mouth, and Neck Diagnoses). These tracheostomy DRGs are extremely heavily weighted due to the immense intensive care resources and prolonged ventilatory monitoring required postoperatively.
🔧 ICD‑10‑PCS Equivalents
| PCS Code | Full Description | Modality |
|---|---|---|
| 0CBS0ZZ | Excision of Supraglottis, Open Approach | Excisional Surgery |
| 07B70ZZ | Excision of Right Neck Lymphatic, Open Approach | Excisional Surgery |
| 07B80ZZ | Excision of Left Neck Lymphatic, Open Approach | Excisional Surgery |
| 0CBT0ZZ | Resection of Larynx, Open Approach | Resectional Surgery |
PCS Character Analysis
| Position | Character | Value | Definition |
|---|---|---|---|
| 1 | Section | 0 | Medical and Surgical. Indicates a standard operative therapeutic intervention. |
| 2 | Body System | C | Mouth and Throat. Encompasses the laryngeal and pharyngeal structural anatomy. |
| 3 | Root Operation | B | Excision. Represents cutting out a partial portion of a distinct body part. |
| 4 | Body Part | S | Supraglottis. Explicitly specifies the precise regional target of the laryngeal excision. |
| 5 | Approach | 0 | Open. Identifies the cutting through the skin and multiple tissue layers to reach the site. |
| 6 | Device | Z | No Device. Confirms that no permanent mechanical device is left behind in the surgical bed. |
| 7 | Qualifier | Z | No Qualifier. Denotes that no additional diagnostic or specific technique attribute is needed. |
Root Operation Comparison
- Excision (B) vs. Resection (T): Excision involves meticulously removing only a portion of a body part (e.g., supraglottis), whereas Resection involves removing the entire body part (e.g., total laryngectomy).
- Excision (B) vs. Destruction (5): Excision physically cuts out the tissue block for pathological review, whereas destruction simply eradicates it (e.g., laser ablation) without extraction.
📝 Coding Examples
Example 1
Clinical Scenario:
A 62-year-old male presents with advanced supraglottic squamous cell carcinoma combined with right-sided cervical lymphadenopathy. The patient is taken to the operating room where the surgeon performs a precise en bloc excision of the epiglottis, aryepiglottic folds, and false vocal cords. Concurrently, a right radical neck dissection is performed, aggressively removing levels I-V lymph nodes, the sternocleidomastoid muscle, and internal jugular vein. The upper airway is carefully reconstructed to preserve true vocal cord function, and the patient is transferred to the intensive care unit.
| Field | Code | Rationale |
|---|---|---|
| CPT | 31368 | This single comprehensive code covers both the supraglottic partial laryngectomy and the concurrent radical neck dissection. |
| PDx | C32.1 | Accurately captures the primary malignant neoplasm localized to the supraglottis. |
Note
Do not report a separate code for the right neck dissection, as it is comprehensively bundled into the very definition of 31368. Billing them together represents fraudulent unbundling.
Example 2
Clinical Scenario:
A 55-year-old female undergoes a subtotal supraglottic laryngectomy combined with a left radical neck dissection to treat an aggressive laryngeal tumor. During the exact same operative session, the surgeon also performs a distinct right-sided modified radical neck dissection due to suspected contralateral metastatic spread. The left and right neck procedures are clearly documented in totally separate operative paragraphs highlighting the distinct anatomical interventions.
| Field | Code | Rationale |
|---|---|---|
| CPT 1 | 31368 | Accounts entirely for the primary supraglottic laryngectomy and the inclusive left radical neck dissection. |
| CPT 2 | 38724-59-RT | Accounts for the distinctly separate modified radical neck dissection performed on the contralateral (right) side. |
| PDx | C32.1 | Indicates the primary laryngeal cancer diagnosis necessitating the surgical intervention. |
Warning
The -59 modifier must be utilized to bypass National Correct Coding Initiative (NCCI) edits, and it must be firmly supported by explicit documentation proving the right neck dissection was a separate, distinct anatomical site.
Example 3
Clinical Scenario:
A 70-year-old patient with laryngeal cancer undergoes a subtotal supraglottic laryngectomy with radical neck dissection. Due to severe, dense scarring from previous extensive radiation therapy, the dissection is extraordinarily tedious, taking nearly three hours longer than a typical case of this exact nature. The primary surgeon provides a highly detailed addendum detailing the intense effort and extra surgical time required to preserve the true vocal cords safely.
| Field | Code | Rationale |
|---|---|---|
| CPT | 31368-22 | The -22 modifier is correctly applied to indicate the substantially increased procedural services stemming directly from the radiation scarring. |
| PDx | C32.1 | Reflects the primary supraglottic tumor being treated during the encounter. |
Global period reminder
All normal post-operative visits, routine wound care, and standard monitoring within the next 90 days are strictly included in the initial payment for this surgery. An E/M code should never be billed during this global period unless the visit is for an entirely unrelated diagnosis.
⚠️ Common Coding Pitfalls
- Pitfall 1: Unbundling the neck dissection. Billing CPT 38720 or 38724 on the same ipsilateral side as the laryngectomy is a major compliance error, as the neck dissection is already explicitly included in 31368.
- Pitfall 2: Misidentifying the laryngectomy type. Incorrectly using 31368 for a total laryngectomy (31365) or a horizontal partial laryngectomy (31370) will rapidly result in inaccurate reimbursement and severe clinical misrepresentation.
- Pitfall 3: Ignoring the 90-day global period. Billing standard evaluation and management (E/M) visits for wound care or routine follow-up within the 90-day window will cause immediate claim denials.
- Pitfall 4: Missing bilateral modifiers on secondary procedures. If a contralateral neck dissection is legitimately performed, failing to use modifier -59 alongside laterality modifiers (-RT/-LT) will lead to automatic bundling rejections.
- Pitfall 5: Lacking diagnostic specificity. Defaulting to an unspecified larynx cancer code (C32.9) when the operative report clearly states a supraglottis subsite (C32.1) significantly compromises organizational HCC risk adjustment scoring.
- Pitfall 6: Inappropriate use of modifier -22. Applying modifier -22 without a comprehensive operative report detailing the explicit clinical reasons for the increased time and technical difficulty will fail subsequent auditor scrutiny.
📎 Sources
[1] AAPC. (2026). CPT® Code 31368 - Excision Procedures on the Larynx - Codify. [2] CMS. (2026). Medicare Physician Fee Schedule and Global Surgery Calculator.