Contractor Information
Contractor Name:
Highmark Medicare Services
Contractor Number:
12102, 12202, 12302
Contractor Type:
MAC Part A & B
LCD Information
LCD Database ID Number
L27488
LCD Title
Diagnostic Laryngoscopy
Contractor’s Determination Number
L27488
AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
Primary Geographic Jurisdiction
Maryland, District of Columbia, Delaware
Oversight Region
Central Office
Original Determination Effective Date
For services performed on or after 07/11/2008
Original Determination Ending Date
N/A
Revision Effective Date
For services performed on or after N/A
Revision Ending Date
N/A
Indications and Limitations of Coverage and/or Medical Necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
The basic otolaryngology examination technique for the upper airway is the indirect mirror examination. This is one aspect of the standard otolaryngological examination, and should be attempted before considering either flexible or rigid laryngoscopy. This indirect mirror procedure may be limited by upper airway anatomy or gagging, but it is reasonable to expect that a practitioner should attempt a mirror exam. If a flexible laryngoscopy is indicated, a practitioner must document that 1) an appropriate diagnostic concern existed, and 2) why the mirror examination failed to provide enough information.
Flexible laryngoscopy is often used to evaluate the upper airway when gagging limits the mirror (indirect) exam, as well as to obtain a more clear view of laryngeal structures when the diagnostic need arises.
Indications
Diagnostic laryngoscopy provides visualization of the upper airway and secondary structures.
Direct Laryngoscopy (CPT/HCPCS code 31515) is direct visualization of the larynx via a rigid scope. Direct laryngoscopy requires the use of monitored or general anesthesia.
Fiberoptic Laryngoscopy (CPT/HCPCS code 31575) is visualization of the larynx via a flexible fiberoptic scope.
This contractor will consider diagnostic laryngoscopy medically reasonable and necessary for visualization of the upper airway when it is done as an initial and/or subsequent diagnostic exam in the diagnosis and treatment of upper airway symptoms and conditions.
The fiberoptic laryngoscopy utilizes specialized endoscopic techniques and is generally the method of choice. However, in certain patients, the rigid laryngoscopy with anesthesia is preferable.
Limitations
Diagnostic laryngoscopy performed in the absence of signs or symptoms of disease or illness will be considered screening, and will be denied as such.
Coverage Topic
Diagnostic Tests and X-rays, Outpatient Hospital Services
Coding Information
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11x | Hospital-inpatient (including Part A) |
12x | Hospital-inpatient or home health visits (Part B only) |
13x | Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) |
83x | Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) |
85x | Special facility or ASC surgery-rural primary care hospital (eff 10/94) |
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
036X | Operating room services-general classification |
045X | Emergency room-general classification |
049X | Ambulatory surgical care-general classification |
051X | Clinic-general classification |
076X | Treatment or observation room-general classification |
CPT/HCPCS Codes
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
31515 | LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; FOR ASPIRATION |
31575 | LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC |
ICD-9 Codes that Support Medical Necessity
It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
FAUCIAL DIPHTHERIA - LARYNGEAL DIPHTHERIA | |
CONJUNCTIVAL DIPHTHERIA - DIPHTHERIA UNSPECIFIED | |
MALIGNANT NEOPLASM OF BASE OF TONGUE - MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED | |
142.0 | MALIGNANT NEOPLASM OF PAROTID GLAND |
142.1 | MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND |
142.2 | MALIGNANT NEOPLASM OF SUBLINGUAL GLAND |
142.8 | MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS |
142.9 | MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED |
145.2 | MALIGNANT NEOPLASM OF HARD PALATE |
145.3 | MALIGNANT NEOPLASM OF SOFT PALATE |
145.4 | MALIGNANT NEOPLASM OF UVULA |
145.5 | MALIGNANT NEOPLASM OF PALATE UNSPECIFIED |
145.6 | MALIGNANT NEOPLASM OF RETROMOLAR AREA |
145.8 | MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH |
145.9 | MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED |
MALIGNANT NEOPLASM OF TONSIL - MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE | |
MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX - MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE | |
MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX - MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE | |
149.1 | MALIGNANT NEOPLASM OF WALDEYER'S RING |
150.0 | MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS |
160.9 | MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED |
MALIGNANT NEOPLASM OF GLOTTIS - MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED | |
162.0 | MALIGNANT NEOPLASM OF TRACHEA |
170.0 | MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE |
173.9 | OTHER MALIGNANT NEOPLASM OF SKIN SITE UNSPECIFIED |
193 | MALIGNANT NEOPLASM OF THYROID GLAND |
194.1 | MALIGNANT NEOPLASM OF PARATHYROID GLAND |
195.0 | MALIGNANT NEOPLASM OF HEAD FACE AND NECK |
196.0 | SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK |
BENIGN NEOPLASM OF TONGUE - BENIGN NEOPLASM OF PHARYNX UNSPECIFIED | |
211.0 | BENIGN NEOPLASM OF ESOPHAGUS |
212.1 | BENIGN NEOPLASM OF LARYNX |
212.2 | BENIGN NEOPLASM OF TRACHEA |
226 | BENIGN NEOPLASM OF THYROID GLANDS |
231.0 | CARCINOMA IN SITU OF LARYNX |
231.1 | CARCINOMA IN SITU OF TRACHEA |
235.1 | NEOPLASM OF UNCERTAIN BEHAVIOR OF LIP ORAL CAVITY AND PHARYNX |
235.6 | NEOPLASM OF UNCERTAIN BEHAVIOR OF LARYNX |
239.0 | NEOPLASM OF UNSPECIFIED NATURE OF DIGESTIVE SYSTEM |
239.1 | NEOPLASM OF UNSPECIFIED NATURE OF RESPIRATORY SYSTEM |
240.0 | GOITER SPECIFIED AS SIMPLE |
240.9 | GOITER UNSPECIFIED |
241.0 | NONTOXIC UNINODULAR GOITER |
241.1 | NONTOXIC MULTINODULAR GOITER |
241.9 | UNSPECIFIED NONTOXIC NODULAR GOITER |
TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM | |
243 | CONGENITAL HYPOTHYROIDISM |
POSTSURGICAL HYPOTHYROIDISM - UNSPECIFIED ACQUIRED HYPOTHYROIDISM | |
ACUTE THYROIDITIS - THYROIDITIS UNSPECIFIED | |
DISORDERS OF THYROCALCITONIN SECRETION - UNSPECIFIED DISORDER OF THYROID | |
288.04 | NEUTROPENIA DUE TO INFECTION |
288.09 | OTHER NEUTROPENIA |
327.20 | ORGANIC SLEEP APNEA, UNSPECIFIED |
327.23 | OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC) |
327.29 | OTHER ORGANIC SLEEP APNEA |
388.70 | OTALGIA UNSPECIFIED |
438.11 | APHASIA |
438.12 | DYSPHASIA |
438.82 | DYSPHAGIA CEREBROVASCULAR DISEASE |
446.4 | WEGENER'S GRANULOMATOSIS |
462 | ACUTE PHARYNGITIS |
464.00 | ACUTE LARYNGITIS WITHOUT OBSTRUCTION |
464.01 | ACUTE LARYNGITIS WITH OBSTRUCTION |
ACUTE LARYNGOTRACHEITIS WITHOUT OBSTRUCTION - ACUTE LARYNGOTRACHEITIS WITH OBSTRUCTION | |
ACUTE EPIGLOTTITIS WITHOUT OBSTRUCTION - ACUTE EPIGLOTTITIS WITH OBSTRUCTION | |
464.4 | CROUP |
465.0 | ACUTE LARYNGOPHARYNGITIS |
472.1 | CHRONIC PHARYNGITIS |
CHRONIC LARYNGITIS - CHRONIC LARYNGOTRACHEITIS | |
478.21 | CELLULITIS OF PHARYNX OR NASOPHARYNX |
478.22 | PARAPHARYNGEAL ABSCESS |
478.24 | RETROPHARYNGEAL ABSCESS |
478.30 | UNSPECIFIED PARALYSIS OF VOCAL CORDS |
478.31 | PARTIAL UNILATERAL PARALYSIS OF VOCAL CORDS |
478.32 | COMPLETE UNILATERAL PARALYSIS OF VOCAL CORDS |
478.33 | PARTIAL BILATERAL PARALYSIS OF VOCAL CORDS |
478.34 | COMPLETE BILATERAL PARALYSIS OF VOCAL CORDS |
478.4 | POLYP OF VOCAL CORD OR LARYNX |
478.5 | OTHER DISEASES OF VOCAL CORDS |
478.6 | EDEMA OF LARYNX |
UNSPECIFIED DISEASE OF LARYNX - OTHER DISEASES OF LARYNX | |
491.1 | MUCOPURULENT CHRONIC BRONCHITIS |
507.0 | PNEUMONITIS DUE TO INHALATION OF FOOD OR VOMITUS |
518.81 | ACUTE RESPIRATORY FAILURE |
519.00 | TRACHEOSTOMY COMPLICATION UNSPECIFIED |
519.01 | INFECTION OF TRACHEOSTOMY |
519.02 | MECHANICAL COMPLICATION OF TRACHEOSTOMY |
519.09 | OTHER TRACHEOSTOMY COMPLICATIONS |
519.11 | ACUTE BRONCHOSPASM |
519.19 | OTHER DISEASES OF TRACHEA AND BRONCHUS |
530.11 | REFLUX ESOPHAGITIS |
530.3 | STRICTURE AND STENOSIS OF ESOPHAGUS |
530.6 | DIVERTICULUM OF ESOPHAGUS ACQUIRED |
733.99 | OTHER DISORDERS OF BONE AND CARTILAGE |
748.2 | WEB OF LARYNX |
748.3 | OTHER CONGENITAL ANOMALIES OF LARYNX TRACHEA AND BRONCHUS |
780.51 | INSOMNIA WITH SLEEP APNEA, UNSPECIFIED |
780.53 | HYPERSOMNIA WITH SLEEP APNEA, UNSPECIFIED |
783.3 | FEEDING DIFFICULTIES AND MISMANAGEMENT |
784.1 | THROAT PAIN |
784.2 | SWELLING MASS OR LUMP IN HEAD AND NECK |
784.41 | APHONIA |
784.49 | OTHER VOICE DISTURBANCE |
784.5 | OTHER SPEECH DISTURBANCE |
784.8 | HEMORRHAGE FROM THROAT |
786.09 | RESPIRATORY ABNORMALITY OTHER |
786.1 | STRIDOR |
786.2 | COUGH |
786.3 | HEMOPTYSIS |
DYSPHAGIA, UNSPECIFIED - OTHER DYSPHAGIA | |
807.5 | CLOSED FRACTURE OF LARYNX AND TRACHEA |
OPEN WOUND OF LARYNX WITH TRACHEA UNCOMPLICATED - OPEN WOUND OF TRACHEA UNCOMPLICATED | |
OPEN WOUND OF LARYNX WITH TRACHEA COMPLICATED - OPEN WOUND OF TRACHEA COMPLICATED | |
925.2 | CRUSHING INJURY OF NECK |
FOREIGN BODY IN PHARYNX - FOREIGN BODY IN LARYNX | |
FOREIGN BODY IN TRACHEA - FOREIGN BODY IN RESPIRATORY TREE UNSPECIFIED | |
935.1 | FOREIGN BODY IN ESOPHAGUS |
BURN OF MOUTH AND PHARYNX - BURN OF ESOPHAGUS | |
959.09 | OTHER AND UNSPECIFIED INJURY TO FACE AND NECK |
989.5 | TOXIC EFFECT OF VENOM |
995.0 | OTHER ANAPHYLACTIC SHOCK NOT ELSEWHERE CLASSIFIED |
V10.01 | PERSONAL HISTORY OF MALIGNANT NEOPLASM OF TONGUE |
V10.02 | PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED PARTS OF ORAL CAVITY AND PHARYNX |
V10.12 | PERSONAL HISTORY OF MALIGNANT NEOPLASM OF TRACHEA |
V10.21 | PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARYNX |
V48.5 | SENSORY PROBLEM WITH NECK AND TRUNK |
Diagnoses that Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity
All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.
General Information
Documentation Requirements
- All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
- The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
- The medical record for these services must include a formal, descriptive narrative. The procedural details and findings should be clearly stated. In instances that require serial or follow-up procedures, the documentation must show how repeat laryngoscopic findings influence the prescribed treatment plan.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Sources of Information and Basis for Decision
Other Contractor’s Policies
Highmark Medicare Services Contractor Medical Directors
Advisory Committee Meeting Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).
CAC/IAC Distribution: 04/01/2008
Start Date of Comment Period
End Date of Comment Period:
05/15/2008
Start Date of Notice Period
05/23/2008
Revision History
Revision History Number
L27488
Revision History Explanation
| Date | Policy # | Description |
|---|---|---|
05/23/2008 |
L27488 |
Original LCD posted for notice. LCD to become effective 07/11/2008 for Maryland Part B, DCMA Part B, and Delaware Part B. |
04/01/2008 |
Draft J12-D16 |
Original LCD posted for comment. |
Last Reviewed On
05/22/2008
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