AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2025 Issue 1; Ask the Editor

Transesophageal Fistulization with Cricopharyngeal Myotomy and Voice Prosthesis Placement

A patient with recurrent squamous cell carcinoma of the larynx presented for total laryngectomy with neck dissection. Following the laryngectomy procedure, reconstruction was performed including tracheoesophageal puncture (TEP) with voice prosthesis placement.During the reconstructive portion of the procedure, the cricopharyngeus muscle was found to be fairly tight. Two cuts were made spreading the muscles apart down to the level of the mucosa. Following the cricopharyngeal myotomy, the trachea was matured, and a primary TEP was performed. An 8-mm voice prosthesis was placed through the fistula tract. Is it appropriate to separately report the myotomy in this case? What is the appropriate ICD-10-PCS code assignment for placement of voice prosthesis following TEP and cricopharyngeal myotomy? ...

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