🗣️ CPT 31395 — Pharyngolaryngectomy, With Radical Neck Dissection; With Reconstruction
Quick Reference
wRVU: 36.65 | 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 and pharynx are midline, singular structures. Assistant surgeons are permitted and payable when supported by medical necessity.
📋 Clinical Description
CPT 31395 describes an extensive en bloc surgical excision of both the larynx and pharynx (pharyngolaryngectomy), combined with a radical neck dissection and primary or tissue-flap reconstruction. The primary intent of this major oncological procedure is the radical eradication of advanced, aggressive malignancies involving overlapping regions of the hypopharynx, larynx, and cervical nodal basins. Unlike non-reconstructive approaches, this code explicitly captures the immediate, intraoperative structural reconstruction required to restore pharyngeal continuity using locoregional or free microvascular tissue transfer.
This procedure is distinguished from CPT 31390, which covers pharyngolaryngectomy with radical neck dissection without primary surgical reconstruction. It is also differentiated from standard total laryngectomy codes (such as CPT 31360 or 31365) which do not encompass the extensive pharyngeal tissue reections or integral pharyngeal flap reconstructions required for advanced hypopharyngeal/laryngeal tumors. Surgeons select CPT 31395 when aggressive primary tumor growth requires wide mucosal resection across both laryngeal and pharyngeal boundaries alongside radical neck dissection and functional flap reconstruction.
This procedure may be performed in the following clinical contexts:
- Advanced Hypopharyngeal or Laryngeal Carcinoma — Indicated for Stage III/IV squamous cell carcinomas spanning the hypopharynx, piriform sinus, and intrinsic laryngeal structures.
- Regional Lymph Node Metastasis — Performed when clinical or radiological findings confirm regional cervical nodal involvement requiring radical lymphadenectomy.
- Post-Radiation Salvage Surgery — Executed as a extensive salvage procedure following local treatment failure or persistent recurrence after primary chemoradiation therapy.
- Pharyngeal Reconstruction Requirement — Indicated when the post-excision defect is too expansive for primary closure, requiring myocutaneous or free flap reconstruction.
- Invasive Upper Aerodigestive Malignancies — Employed for rare aggressive malignancies such as mucosal melanoma, adenocarcinoma, or sarcoma invading the pharyngolaryngeal complex.
🔬 Anatomical & Procedural Considerations
| Variant | Mechanism | Key Notes |
|---|---|---|
| Resection Phase | En bloc surgical excision of the complete laryngeal framework and involved pharyngeal walls through an open cervical approach. | Involves circumferential or near-circumferential removal of the laryngeal cartilages, hyoid bone, epiglottis, and pharyngeal mucosa. |
| Ipsilateral Neck Dissection | Radical neck dissection performed on the side of primary lymphatic basin drainage. | Clearance includes levels I-V lymph nodes, internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve. |
| Reconstructive Phase | Creation and inset of myocutaneous flaps (e.g., pectoralis major) or free tissue transfer (e.g., anterolateral thigh or radial forearm). | Restores alimentary tract continuity between the posterior tongue/oropharynx and cervical esophagus to allow postoperative deglutition. |
Clinical Pearl
CPT 31395 includes the structural reconstruction of the pharyngeal defect when performed during the same operative session. However, if a separate microvascular free flap surgery (e.g., CPT 43496 or 15756) is executed by a distinct co-surgeon, careful review of operative reports and individual payer guidelines is required to determine whether separate reconstructive coding with co-surgeon modifiers (-62) is allowable.
✅ Procedure Includes
- Surgical exposure, vessel ligation, and dissection through an extensive open anterior cervical incision.
- Total resection of the larynx, hyoid bone, and involved pharyngeal walls (pharyngolaryngectomy).
- Full radical neck dissection encompassing cervical lymph node levels I-V and adjacent non-lymphatic structures.
- Intraoperative flap design, elevation, inset, or primary reconstructive repair of the pharyngeal defect.
- Routine surgical drain placement and creation of a permanent end tracheostoma for airway management.
- Immediate post-operative wound care, tube management, and initial ICU monitoring.
❌ Excludes / Do Not Report Together
| Code | Description | Relationship |
|---|---|---|
| 31390 | Pharyngolaryngectomy, with radical neck dissection; without reconstruction | Mutually exclusive; 31395 includes the reconstructive phase of the procedure. |
| 31365 | Laryngectomy; total, with radical neck dissection | Mutually exclusive; represents a total laryngectomy without pharyngeal wall resection or pharyngeal reconstruction. |
| 38720 | Cervical lymphadenectomy (complete) | Inclusively bundled; the radical neck dissection component is inherently included in 31395. |
| 31600 | Tracheostomy, planned | Bundled when performed as part of the surgical approach and airway establishment during radical laryngectomy. |
Bundling Alert
CPT 31395 carries a 90-day global surgical period. All routine preoperative work, intraoperative procedures (including the neck dissection and primary reconstruction), and postoperative care within 90 days are bundled into the primary code reimbursement. Do not report ipsilateral neck lymphadenectomy or primary pharyngeal closure separately.
🌳 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 (Global: 090)
│ ├── 31390 Pharyngolaryngectomy, with radical neck dissection; without reconstruction (Global: 090)
│ └── ▶▶ 31395 ◀◀ Pharyngolaryngectomy, with radical neck dissection; with reconstruction ← YOU ARE HERE (Global: 090)
💰 RVU & Reimbursement Profile
| Component | Value |
|---|---|
| Work RVU | 36.65 |
| 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 31395 carries a bilateral indicator of “0,” indicating that the 150% bilateral surgical payment adjustment is not applicable. The larynx and pharynx are midline anatomical structures. If a bilateral radical or modified neck dissection is performed, report CPT 31395 for the pharyngolaryngectomy and primary neck dissection, and report the contralateral neck dissection using a distinct CPT code (such as 38724) with modifier -59 and appropriate laterality modifiers (-RT/-LT).
🏷️ Modifier Reference
| Modifier | Name | When to Apply |
|---|---|---|
| -22 | Increased Procedural Services | Apply when severe radiation fibrosis or extensive scar tissue requires substantially increased operative time and technical effort. |
| -52 | Reduced Services | Apply if the planned reconstruction or neck dissection portion is aborted or significantly reduced. |
| -53 | Discontinued | Apply if the surgical procedure is terminated after anesthesia induction due to acute patient hemodynamic instability. |
| -58 | Staged | Apply if a subsequent planned reconstructive or revisional procedure is performed during the 90-day global period. |
| -59 | Distinct Service | Apply when billing a separate non-bundled procedure at 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 post-operative complications like hematoma or flap failure. |
| -79 | Unrelated Procedure | Apply if an unrelated surgical procedure is performed by the same surgeon during the 90-day global period. |
| -80 | Assistant Surgeon | Apply when a second qualified surgeon directly assists with the resection, dissection, and complex closure. |
| -82 | Assistant Surgeon (No Resident) | Apply in teaching institutions when a qualified surgical resident is unavailable to assist. |
(Note: Modifiers -RT, -LT, -50, -24, and -51 generally do not apply to the base primary code due to the midline nature of the laryngeal/pharyngeal structures).
🩺 Common ICD‑10‑CM Pairings
Primary Diagnosis Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| C32.8 | Malignant neoplasm of overlapping sites of larynx | Yes | Used when cancer involves multiple sub-sites of the larynx extending into the pharynx. |
| C32.9 | Malignant neoplasm of larynx, unspecified | Yes | Assigned for laryngeal malignancies when explicit sub-site details are unavailable. |
| C14.0 | Malignant neoplasm of pharynx, unspecified | Yes | Captures primary pharyngeal malignant neoplasms requiring radical surgical extirpation. |
| C13.9 | Malignant neoplasm of hypopharynx, unspecified | Yes | Represents a primary indication when hypopharyngeal tumors cross into the laryngeal framework. |
| C77.0 | Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck | Yes | Primary secondary code justifying the medical necessity of the radical neck dissection component. |
Secondary Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| Z85.810 | Personal history of malignant neoplasm of tongue | No | Indicates relevant historical head and neck oncological diagnoses. |
| Z87.891 | Personal history of nicotine dependence | No | Identifies documented personal history of tobacco exposure. |
Etiology / Complication
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| F17.210 | Nicotine dependence, cigarettes, uncomplicated | No | Documented active tobacco use contributing to upper aerodigestive tract malignancies. |
| F10.20 | Alcohol dependence, uncomplicated | Yes | Common synergistic risk factor associated with squamous cell carcinomas of the head and neck. |
Coding Specificity Reminder
🏥 MS‑DRG Considerations
Inpatient admissions for CPT 31395 map to MS-DRG 129, 130, or 131 (Major Head and Neck Procedures), divided based on the presence of Major Complications and Comorbidities (MCC) or Complications and Comorbidities (CC). If a formal tracheostomy is performed, the admission may re-group to MS-DRG 011, 012, or 013 (Tracheostomy for Face, Mouth, and Neck Diagnoses), which carry significantly higher relative weights to account for prolonged post-operative ventilatory support and intensive care resource utilization.
🔧 ICD‑10‑PCS Equivalents
| PCS Code | Full Description | Modality |
|---|---|---|
| 0CBT0ZZ | Resection of Larynx, Open Approach | Resectional Surgery |
| 0CBR0ZZ | Resection of Pharynx, Open Approach | Resectional Surgery |
| 07B70ZZ | Excision of Right Neck Lymphatic, Open Approach | Excisional Surgery |
| 07B80ZZ | Excision of Left Neck Lymphatic, Open Approach | Excisional Surgery |
PCS Character Analysis
| Position | Character | Value | Definition |
|---|---|---|---|
| 1 | Section | 0 | Medical and Surgical section. |
| 2 | Body System | C | Mouth and Throat body system. |
| 3 | Root Operation | T | Resection: Cutting out or off, without replacement, all of a body part. |
| 4 | Body Part | R | Pharynx structure. |
| 5 | Approach | 0 | Open approach: Cutting through skin/mucous membrane and exposing the site. |
| 6 | Device | Z | No device remaining at surgical site. |
| 7 | Qualifier | Z | No qualifier needed. |
Root Operation Comparison
Resection (T): Involves removing the entire anatomical body part (e.g., complete excision of larynx or pharynx).
Excision (B): Involves removing a portion of a body part (e.g., partial lymph node dissection or subtotal resection).
📝 Coding Examples
Example 1
Clinical Scenario: A 64-year-old male with persistent Stage IV squamous cell carcinoma involving overlapping regions of the hypopharynx and subglottic larynx undergoes definitive surgery. The otolaryngologist performs an open circumferential en bloc excision of the larynx, hyoid bone, and involved pharyngeal walls. Simultaneously, a right radical neck dissection is executed, removing level I-V lymph nodes, internal jugular vein, and sternocleidomastoid muscle. Primary reconstruction of the pharyngeal defect is accomplished during the same operative setting using a regional myocutaneous flap, and a permanent end tracheostoma is established.
| Field | Code | Rationale |
|---|---|---|
| CPT | 31395 | Captures the complete pharyngolaryngectomy with radical neck dissection and primary reconstruction. |
| PDx | C32.8 | Identifies primary malignant neoplasm of overlapping sites of the larynx. |
Note
The neck dissection and pharyngeal reconstruction are fully bundled into CPT 31395 and should not be separately billed.
Example 2
Clinical Scenario: A 58-year-old female with recurrent hypopharyngeal carcinoma presents for radical surgical resection. The primary surgeon performs a pharyngolaryngectomy with left radical neck dissection and primary flap reconstruction. Concurrently, due to documented contralateral nodal disease, a distinct modified radical neck dissection is performed on the right neck. Operative documentation details separate incisions and distinct surgical work for the contralateral neck dissection.
| Field | Code | Rationale |
|---|---|---|
| CPT 1 | 31395 | Covers the primary pharyngolaryngectomy, left radical neck dissection, and reconstruction. |
| CPT 2 | 38724--59--RT | Reports the distinct, non-bundled modified radical neck dissection on the contralateral (right) side. |
| PDx | C13.9 | Specifies primary malignant neoplasm of the hypopharynx. |
Warning
Modifier -59 is required on the secondary neck dissection code to confirm distinct procedural work on the contralateral neck basin.
Example 3
Clinical Scenario: A 67-year-old male with extensive post-radiation fibrosis undergoes a planned salvage pharyngolaryngectomy with radical neck dissection and complex flap reconstruction for recurrent laryngeal cancer. Severe scarring and altered tissue planes significantly complicate dissection around critical neurovascular structures, increasing total operative time by more than three hours beyond standard expected duration. Detailed operative notes explicitly document the substantial difficulty and extended time required.
| Field | Code | Rationale |
|---|---|---|
| CPT | 31395--22 | Modifier -22 indicates substantially increased procedural services secondary to radiation fibrosis. |
| PDx | C32.9 | Represents malignant neoplasm of larynx, unspecified. |
Note
Comprehensive operative documentation detailing the specific clinical challenges and extra surgical time is required to support modifier -22 submission.
⚠️ Common Coding Pitfalls
- Pitfall 1: Unbundling primary reconstruction. Billing separate tissue flap codes for primary pharyngeal closure when reconstruction is included in CPT 31395.
- Pitfall 2: Separately reporting ipsilateral neck dissection. Submitting CPT 38720 or 38724 for the same side as the pharyngolaryngectomy.
- Pitfall 3: Confusing 31390 and 31395. Reporting 31390 when reconstruction is performed, or reporting 31395 when no reconstruction occurs.
- Pitfall 4: Billing routine post-operative E/M services. Submitting follow-up visits within the 90-day global surgical period without an unrelated diagnosis and modifier -24.
- Pitfall 5: Missing contralateral laterality modifiers. Failing to append modifier -59 and laterality modifiers when a separate contralateral neck dissection is performed.
- Pitfall 6: Using unspecified diagnosis codes when sub-site specificity (e.g., overlapping sites C32.8) is clearly detailed in pathology and operative reports.
📎 Sources
[1] AMA. (2026). Current Procedural Terminology (CPT®) Professional Edition. American Medical Association. [2] CMS. (2026). Medicare Physician Fee Schedule Relative Value Files and Global Surgery Rules. Centers for Medicare & Medicaid Services.