Medically necessary reasons that support this scope include but are not limited to:

• Macroglossia preventing mirror exam
• Gag reflex preventing mirror exam
• Patient unable to cooperate to allow mirror exam due to age or mental condition
• Hoarseness, dysphasia, aspiration not clearly evaluated by indirect laryngoscopy
• Lesion identified by mirror exam needing further evaluation
• Anterior commissure not completely visualized by mirror exam
• Aspiration suspected that cannot be evaluated by mirror exam
• Evaluation of the larynx and immediate subglottis in patients for tracheal decannulation
• Acute airway obstruction

Remember, using a mirror, 31505 to perform an exam of the throat, oropharynx, etc. is part of the E/M service based on 1997 E/M guidelines.

Supporting diagnosis for 31575 include:

• Airway obstruction – chronic 496; NEC 519.8
• Aspiration, chronic 507.0
• Cough, chronic 786.2
• Dysphagia 787.2x
• Dyspena 786.09
• Foreign body 933.1 – larynx
• Head and neck mass 784.2
• Hemoptysis 786.3
• History of tobacco use V15.82
• Hoarseness, chronic 784.49
• Laryngeal trauma 959.09
• Neoplasm suspected
• OSA – severe snoring 327.23
• Otalgia 388.70
• Stridor 786.1
• Throat pain 784.1

Make sure your documentation supports your decision to perform this exam.

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