By Tanya Allgood, RHIT, CCS
The larynx, also called the voice box, is the organ that produces sound, passes air for breathing, and keeps food from passing into the lower respiratory tract. The larynx has three main parts: the supraglottis, which includes the epiglottis; the glottis, which includes the vocal cords; and the subglottis.
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Understanding the anatomy of the larynx is important to ensure correct coding of diagnoses and procedures. The part of the larynx that tends to cause confusion for coders is the vocal cords and the subglottic area.
Most of the time, the subglottic area is identified in coding by the larynx. The glottis contains the vocal cords and the subglottis is below the glottis and vocal cords. To ensure correct coding of procedures, the provider would need to identify on which part of the larynx the procedure is being performed. For example, in ICD-10 PCS, biopsy of the vocal cords would lead to 0CBVxxx, and if no documentation of specificity – only documented as larynx – that would lead to 0CBSxxx. Many times, the documentation only has the term larynx, so it is important as coders and clinical documentation specialists to ensure the provider is documenting to the highest level of specificity.
If the documentation has a diagnosis for vocal cords but only larynx in the procedure, this would be an opportunity to query for specificity to ensure the procedure is coded to the correct CPT or PCS code.
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