# Revision Septorhinoplasty Help



## rgeib (Jul 19, 2017)

So I'm debating which way to go on the following (most relevant sections have been highlighted):

PREOPERATIVE DIAGNOSIS:  Nasal deformity.

POSTOPERATIVE DIAGNOSIS:  Nasal deformity.

OPERATION:  Revision of septorhinoplasty with septal cartilage
grafting.

    The patient was taken to the operating room, placed on the
    operating table in a supine position and sedated and placed under
    general anesthesia.  An IV tube was placed and secured to the
    midline lower lip position.  Total IV anesthesia was used for this
    procedure.  The bed was turned 90 degrees from Anesthesia for the
    procedure.  A surgical time-out was performed and the consents were
    verified.  The patient was prepped and draped in a sterile fashion
    for this procedure.  The nose was topically decongested with
    Afrin-soaked nasal pledgets.  The nose was then injected with local
    anesthesia consisting of 1% lidocaine with 1:100,000 concentration
    of epinephrine.  After allowing several minutes for the epinephrine
    and local anesthesia to take full effect, procedure began with
    septal cartilage harvest.  *A complete transfixion incision was made*
    and extended down below the level of the medial crural footplate
    attachment to the septum in order to help with some tip
    de-projection. * A subsequent left-sided mucoperichondrial flap was
    then raised exposing the nasal septal cartilage. * Great care was
    taken to maintain the integrity of the mucoperichondrial flap at all
    times.  A chondrotomy was then made 2 cm posterior to the caudal
    edge of the nasal septum and *a subsequent right-sided
    mucoperichondrial flap was then raised exposing the quadrangular
    cartilage of the nasal septum where a rectangular portion of the
    quadrangular cartilage was harvested to be used for grafting
    purposes,* which extended 2 cm caudal to the nasal septum,
    posteriorly to the bony cartilaginous junction leaving a minimal 2
    cm x 2 cm L strut of cartilage dorsally and caudally. * Additionally,
    portion of the removed cartilage was crushed in a caudal crusher and
    then replaced between the mucoperichondrial flaps prior to coapting
    the flaps together with a 4-0 plain gut suture in a whipstitch
    fashion.*  The incomplete transfixion incisions were then closed with
    interrupted 5-0 chromic sutures.  A slight 1 to 2 mm tip
    de-projection was achieved with a complete transfixion incision by
    extending it down below the level of the medial crural footplate
    attachment to the nasal septum disrupting this major tip support.
    Next, an open rhinoplasty approach was performed.  A mid columellar
    inverted V incision was marked.  *Incisions were then made along the
    lateral portion of the columella,* which were joined to the mid
    columellar incision and further incisions along the caudal edge of
    the lower lateral cartilages were carried up in the standard open
    rhinoplasty fashion and using both sharp and blunt dissection, the
    skin and soft tissue envelope was dissected off the lower lateral
    cartilages.  The nasal tip cartilages were noted to be intact and
    slightly asymmetric.  The lateral crus of both lower lateral
    cartilages was aggressively previously resected with less than 3 mm
    of lateral crus remaining bilaterally.  Significant subcutaneous
    scar tissue was encountered and wide dissection of the skin and soft
    tissue envelope was performed.  *Dissection continued onto the
    cartilaginous dorsum proceeding up to the bony dorsum where a
    transition to subperiosteal dissection was performed.*  Wide
    undermining of the skin and soft tissue envelope was performed in
    order to help release any scar tissue contracture.  The mid vault
    area was noted to be weakened and in order to address this and
    strengthen the mid vault and the dorsal cartilaginous septum,
    bilateral spreader grafts were used.  The upper lateral cartilages
    were separated from their attachments to the dorsal nasal septum and
*spreader grafts which extended from the caudal edge of the nasal
    bones to the anterior septal angle were shaped from the previously
    harvested quadrangular cartilage and secured to the midline septum*
    on either side with 5-0 PDS mattress sutures.  This was followed by
    re-suspension of the upper lateral cartilages to the spreader grafts
    into the dorsal nasal septum with additional 5-0 PDS sutures.  This
    allowed for straightening and support to the mid vault region.
    Next, attention was drawn toward improvement to the concavities to
    the supra-alar region, which was noted to be secondary to aggressive
    resection of previous lateral crura.  In order to address this
    situation, a lateral crural onlay graft technique was used.  *Grafts
    carved from the previously harvested septal cartilage were used,* 
    which extended from just posterior to the nasal dome to the entire
    length of the lateral crus bilaterally and was secured to the
    remnant of the lateral crura bilaterally with 5-0 PDS sutures.  This
    allowed for improved support to the lateral crura as well as
    correcting the deep conchae cavity to the supra-alar region.  The
    edges of the grafts were beveled appropriately in order to prevent
    any irregularities showing through the skin.  *Next, attention was
    drawn toward the nasal tip and dome region, where the slight
    asymmetry was corrected with tip suturing to include single and
    double dome sutures.  A small soft tissue graft was placed over the
    nasal domes in order to help prevent against any irregularities
    given the patient had relatively thin skin. * Next, in order to
    firmly establish his tip height as well as rotation,
    tongue-in-groove technique was used where the medial crura and
    medial crural footplates were separated from their attachments,
    mobilized, and then secured to the caudal septum with 5-0 PDS
    sutures positioning them allowing for adequate tip position and
    rotation.  The skin and soft tissue envelope was then redraped over
    the bony cartilaginous frame and once again, the patient was checked
    for adequate tip support, symmetry, as well as rotation and
    projection.  Fine adjustments were made accordingly.  Next, the
    incisions were then closed with mid columellar incision closed with
    interrupted 6-0 Prolene sutures.  The marginal incisions were closed
    with interrupted 5-0 chromic sutures.  The lateral columella portion
    incisions were closed with interrupted 6-0 fast-absorbing gut
    sutures.

    Attention was then drawn toward the nasal base and reduction of the
    patient's nostril flare.  This was performed through modified Weir
    excisions.  A marking pen was used to mark crescent shaped incisions
    along the nasal facial junction extending into the nasal alar base
    with great care taken not to disrupt the natural boundary between
    the nasal alar junction.  Local anesthesia was then used to inject
    these areas.  *A #11 blade was then used to excise a portion of the
    nasal ala and extending into the nasal base.  This allowed for an
    advancement rotation flap essentially to reduce the nasal alar base.* 
    3 mm of alar were removed bilaterally.  The incisions were then
    closed with combination of interrupted 5-0 PDS sutures followed by
    vertical mattress sutures of 5-0 Prolene extranasally and intranasal
    vertical mattress sutures using 5-0 plain gut sutures.  The patient
    was again checked for adequate symmetry and support prior to
    completion.  Telfa tacos coated in bacitracin ointment were placed
    in the left and right nasal cavity to be removed by the patient on
    postoperative day 1.  This completed the procedure.  The patient was
    then turned back to Anesthesia, where he was awakened, successfully
    extubated, and taken to the recovery room in stable condition.  He
    tolerated this procedure well without complications.

My original thinking was to just code 30420 for septorhinoplasty, but as this is stated to be revision surgery, should I be coding from 30410-30430 along with 20912 for the septal graft? Typically, I never code septal grafts separately, but I'm not sure here since it was obtained through a separate incision. Also, should I be coding for the mentioned nasal ala rotation flap? Any help would be appreciated. Thanks.


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## JenniferB7 (Jul 19, 2017)

I think you are looking at CPT code 30450, which is a revision rhinoplasty with nasal tip work and osteotomies.

My Procedure Desk Reference / AAPC coder describes this code as:

A rhinoplasty is performed either through the open or closed approach. In an open approach, transfixion and infracartilagenous (rim) incisions are made. Closed approaches can be performed through a number of approaches such as an intercartilagenous incision, infracartilagenous incision, transfixion incision , etc.

Clinical Responsibility
When the patient is appropriately prepped and anesthetized, the provider performs a rhinoplasty either through an open or closed approach. In an open approach, the skin of the nose is opened and raised. In a closed approach, small incisions such as a inter or infracartilagenous incisions are made. In either approach, the necessary changes are made to the bone, cartilage, and soft tissue as desired.  The provider performs lateral and transverse osteotomies and the nasal bones are infractured. 
 The nasal cartilaginous areas are then smoothed to straighten the nose and a graft may also be placed.  A major nasal tip plasty is also done and this is performed by working on the lower lateral cartilage and narrowing it in the region of the dome by removing an equal portion of lateral and medial crura leaving the cartilage at the domal area.  Finally, the wound is closed with transmucosal sutures, adhesive tapes, and splints. To make the nasal tip narrower in a closed rhinoplasty, cartilage can be removed from within the nose.

Terminology
Osteotomy: Cutting into bone; bone incision.

Primary repair: Any repair of an acute injury completed within the first 24 hours after the injury. It involves direct surgical correction of the injury.
Rhinoplasty: Cosmetic surgery of the nose; nasal reconstruction.
Secondary repair: A repair performed after two weeks from the date of the injury; it may include tendon grafts or other more complex procedures.​
Based on the description above (and article below), the septal graft would be included, but the advanced rotation flap would be separately reported with 14060.

Helpful article:  Understand Functional Rhinoplasty Procedures

Hope that helps!


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## rgeib (Jul 20, 2017)

Thanks, Jennifer! This was very helpful!


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## JenniferB7 (Jul 29, 2017)

You are most welcome!

Sorry for the delay in responding.  I was preparing for a certification exam I took today.


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