# Open reduction of 12 year old nasal fracture



## jaimewicklund

Hi folks-

So I am new to ENT coding (I typically code general surgery) so this may be elementary to most of you...but here goes. My doc wants to use cpt code 21336 for this procedure. I don't think this is correct. I am inclined to believe that 21336 is for current fractures that failed failed a closed reduction. This happened 12 years ago...no treatment...now deviated. Would this be a septoplasty??? Also, can anyone suggest where I might find guidelines for this to present if in fact I am correct? Thanks for taking a look!!!:


PREOPERATIVE DIAGNOSIS:  Nasal obstruction.

POSTOPERATIVE DIAGNOSIS:  Nasal obstruction.

PROCEDURE  PERFORMED:  Open reduction, nasal septal fracture.

INDICATIONS:  Mr X is a 16-year-old who presents with a history of
nasal fracture when he was 4 years old.  He fell down, severely
fracturing his nose.  He did not get it fixed at that point, and ever
since that time he has had difficulty breathing through his nose.  In
the office, he was noted to have about a 90-degree deflection of the
caudal septum.

FINDINGS AT THE TIME OF SURGERY:  He was found to have again about a
90-degree deflection of the caudal septum.  The caudal end stuck into
the right nostril, but he had a sharp convexity into the left nostril,
totally blocking that side of his airway.  He also had a posterior bony
spur into the left side, and the maxillary crest was deviated over to
the left as well.

DESCRIPTION OF PROCEDURE:  Once informed consent was obtained, he was
brought to the operating room and placed under general anesthesia.  He
was prepped and draped in the usual fashion.  Nose was injected with 1
percent lidocaine with epinephrine after decongestion with Afrin.  An
incision was made along the ____________________ end of the septum in
the right nostril after prepping and draping.  A mucoperichondrial flap
was raised back on the right side.  A small tear was made, but this was
controlled.  The flap was elevated without tearing, going posteriorly
back past the bony cartilaginous junction.

Attention was turned to the left side.  Mucoperichondrial flap was
raised back on this side as well.  Again, a small little tear was made
at the edge of the sharp angulation.  However, it was controlled
actually very well.  I was able to minimize it to almost nothing.  Next,
raised back, going posteriorly, the caudal septum was just very flail
and completely almost separate from the remaining septum, and this was
removed.  The remaining caudal septum had a deflection in the left side.
 Using a swivel knife, this portion of cartilage was removed.  It was
removed down to a small strip along the maxillary crest.  This was taken
out and placed in saline on the back table.  The lower crest was still
deviated to the left.  This was fractured over.  Bone was removed.  The
strip of cartilage was removed and placed in saline as well.

There was a large bony spur going posteriorly on the left side into the
inferior turbinate.  This was removed.  Did get some minor tearing in
that area on the left side, not the right.  Once this was done, the nose
was reexamined.  There continued to be a little bit of caudal septum
deflected to the right.  This was removed.  The remaining dorsal strut
was in good shape.  It was morcellized on its concave side to help
straighten it out.  This did seem to straighten it out somewhat and move
it more towards the midline.

The large piece of quadrangular cartilage that was removed was
crosshatched to straighten it out.  Once it was nice and straight, it
was placed back in the pocket and pulled anteriorly up to the crura.  It
was sewn to the dorsal strut and to the mucosal flap.  The inferior
strip of cartilage was then placed into the wound inferiorly along where
the maxillary crest had been removed.  The flaps were then
reapproximated anteriorly using a chromic suture.  A coaptation stitch
was then placed, and then splints were placed.  He was turned back to
anesthesia, awakened, and taken to recovery.


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## RebeccaWoodward*

My initial hunch was 30520; however, I was able to locate this article.


Sometimes the otolaryngologist has to repair damage from a nasal fracture that occurred a long time ago because the patient has a deviated septum – among other things – that is causing breathing problems. But unless the otolaryngologist includes other diagnoses (other than just a deviated septum) that show that the repair was medically necessary, some payers may not reimburse the procedure.

Many payers consider the repair of a deviated septum as a cosmetic procedure unless you can show that the patient’s health is affected. To indicate that the repair procedure was medically necessary, you need to include another diagnosis, or a sign or symptom, supported by the physician’s notes

*Example:* The otolaryngologist treats a female patient with a deviated septum and ethmoidal sinusitis that is not responding to antibiotic treatment. He learns that when the patient was a youngster, she broke her nose playing baseball. At the time the nasal fracture was repaired by closed treatment with stabilization (21320); prior to the incident, the patient had no breathing or sinus problems. The otolaryngologist decides to perform a septoplasty (30520) and a partial ethmoidectomy (31254) to repair the deviated septum and treat the sinusitis.

To get paid for the septoplasty, the otolaryngologist has to document the nasal obstruction that informed his decision to perform the septoplasty. If the otolaryngologist notes that the septoplasty was performed first to provide easy access to the sinus, you’re sunk. Instead, inform the otolaryngologist to include the medical reason the septoplasty was performed ( it may not be enough to simply note that there was a nasal obstruction.)The otolaryngologist should note the percentage of obstruction in each nostril; for example, ‘the patient has an S-curvature septum that causes a 70% obstruction on the right and an 80% obstruction on the left. During rhinitis and allergy season, there is total obstruction.

As for the claim itself, it is recommended that you list the diagnosis that provides medical necessity for the procedure first. In some geographic locations, the deviated septum alone provides medical necessity, but elsewhere, you need to list the nasal obstruction first, because that’s why the patient with the deviated septum saw the otolaryngologist in the first place. In the case described above, she’d use 478.1 (other diseases of nasal cavity and sinuses) as the primary diagnosis and 470 (deviated nasal septum) secondarily. For the ethmoidectomy, the correct diagnosis code is 473.2 (ethmoidal sinusitis). Although the examples of 478.1 listed in the ICD-9 manual are unrelated to nasal obstruction, the Index to Diseases in the Manual points to 478.1 for this condition.

Note: Although many payers bundle septoplasties with endoscopic sinus surgery, this is inappropriate because the two procedures are performed for separate conditions, according to the AmericanAcademy of Otolaryngology – Head and Neck Surgery, which states: “Most commonly, the septal deformity is blocking the nasal airway and obstructing the patient’s breathing. This is independent of the sinus pathology and performing the sinus operation alone would be insufficient to correct the pathology.”

In some cases, the late repair of a nasal fracture involves more than repairing a deviated septum.Sometimes the otolaryngologist also has to refracture the nasal bone as well as repair the septum, which you report using 21335 (open treatment of nasal fracture; with concomitant open treatment of fractured septum).In such cases you should also include ICD-9 code 802.0 (fracture of nasal bones, closed). This lets the insurer know why you had to do more than a septoplasty, noting that some payers may also want to see 905.0 (late effect of fracture of skull or face bone) before being convinced that the nasal refracture was medically necessary.

If the patient also has a severe nasal deformity, the otolaryngologist may decide that functional rhinoplasty with septal repair (30420) is necessary.  Because payers immediately associate rhinoplasty with cosmetic procedures, the claim likely will be denied on first submission, even if the diagnosis codes indicate medical necessity, and you’ll have to submit the claim with supporting documentation before payment becomes even a possibility.


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