A patient with dysphagia, cricopharyngeal dysfunction and spasm with Schatzki’s ring, presents for Botox injection into the cricopharyngeus. After general anesthesia is provided, a direct laryngoscopy and direct hypopharyngoscopy was performed. A microscope was used for direct visualization. Botox was injected into three areas of the posterior cricopharyngeus. The coders at our facility have been debating between codes 31571 and 64613. What is the appropriate code assignment for direct laryngoscopy with injection of Botox into the cricopharyngeal muscle using an operating microscope?
It would be inappropriate to report CPT code 31571, Laryngoscopy, direct, with injection into vocal cord(s), therapeutic, with operating microscope or telescope, because based on the operative report submitted, the injection was made in the neck muscles and not the vocal cords. Therefore, report CPT code 64613, Chemodenervation of muscles(s); neck muscle(s) (eg, for spasmodic torticollis, spasmodic dysphonia), and CPT code 31528, Laryngoscopy direct, with or without tracheoscopy; with dilation, initial, for the procedures performed.