CPT® Code 31528

A direct laryngoscopy is a medical procedure that allows a physician to visualize the larynx and surrounding structures using a specialized instrument known as a laryngoscope. This procedure can be performed with or without the use of tracheoscopy, which involves examining the trachea. The laryngoscope can be either rigid or flexible; the choice of scope depends on the specific clinical situation. A flexible laryngoscope is typically inserted through the nostril, while a rigid laryngoscope is inserted through the mouth. During the examination, the physician inspects various anatomical areas, including the nasopharynx, oral cavity, oropharynx, hypopharynx, and larynx, for any signs of abnormalities or injuries. If any stenosis, or narrowing of the airway, is detected, the physician will identify the location and measure the length and width of the stricture. Additionally, any areas of malacia (softening of the tissue) or scarring, such as granulation tissue, will be noted. Following the visualization, a dilation laryngoscope or tracheoscope is advanced to the site of the stenosis. The conical tip of the dilation instrument is then carefully passed through the narrowed region and left in place for a duration of 5 to 10 minutes to facilitate dilation. This procedure is coded as CPT® Code 31528 for the initial dilation, while subsequent dilation procedures are coded as CPT® Code 31529.