# Help with ENT coding



## jaldrich (Jun 5, 2009)

I am having trouble with the "rhinoseptoplasty" portion.  It was originally coded as 30420, but I'm wondering if that's right? Any one with more experience who can tell me how this should be coded? ENT is not my strong suit! 
Thanks in advance,
Jennifer

SERVICE:  HEAD AND NECK SURGERY  

DAY SURGERY REPORT  

PREOPERATIVE DIAGNOSES  

1. Acquired nasal deformity.  

2. Deviated nasal septum.  

3. Turbinate hypertrophy.  

4. Chronic maxillary sinusitis with bilateral conchae bullosa.    

POSTOPERATIVE DIAGNOSES  

1. Acquired nasal deformity.  

2. Deviated nasal septum.  

3. Turbinate hypertrophy.  

4. Chronic maxillary sinusitis with bilateral conchae bullosa.    

OPERATIVE PROCEDURES  

1. Rhinoseptoplasty.  

2. Turbinate reductions.    

3. Endoscopic conchae bullosa resection.    

 TYPE OF ANESTHESIA:  General endotracheal.  

 ESTIMATED BLOOD LOSS:  100 mL of fluids per Anesthesia.    



FINDINGS  

1. Significantly deviated caudal septum to the left with obstruction of the left external valve.    

2. Mid portion deflection of the septum to the right.    

3. Widened nasal dorsum with slight open-roof deformity.  

4. Poor tip support.    


SPECIMENS:  None.    


COMPLICATIONS:  None.  


DISPOSITION:  PACU, extubated, stable.    

INDICATIONS FOR PROCEDURE:  The patient is a 43-year-old female with a history of chronic nasal obstruction and chronic rhinosinusitis symptoms with significant external nasal deformity and obstruction of the left external valve.  She has been tried on medical therapy with oral antihistamines and nasal steroids.  She was offered surgical intervention as this is a fixed anatomical obstruction.  She wished to proceed and informed consent was obtained.    

PROCEDURE  

After general anesthesia, nasal cavity was topically anesthetized with 4% soaked cocaine pledgets, and the septum was injected with 1% Xylocaine with 1:100,000 epinephrine, total 6 mL used.  The patient was prepped and draped in standard fashion for this case.  Hemitransfixion incision was carried out on the right side and elevated completely on this side.  The left side was approached going anteriorly around the caudal septum.  This was necessary secondary to the significant caudal septum deflection onto the left side.  Tunnels were created superiorly and inferiorly so there was still attachment of the mucosa to the cartilaginous septum.  The bony cartilaginous junction was separated.  The bony septum was isolated.  There was moderate deflection primarily posteriorly to the left.  This was removed by taking bites superiorly and inferiorly of this and removing.  The cartilaginous septum was freed off the maxillary crest.  The redundant cartilaginous septum inferiorly was trimmed.  The caudal septum deflection was trimmed sharply.  With this, there was some tip laxity.  As such, the cartilaginous septum was secured to the maxillary crest with interrupted PDS suture.  This gave good tip support.  Portions of the septum that had been removed were morselized and replaced as necessary.    



Endoscopically, the root of the middle turbinate was identified on the right.  The lateral portion of the middle turbinate was opened and removed with microdebrider under endoscopic guidance to uncover the conchae bullosa.  This was repeated on the left side without deviation.  The middle turbinate was pushed medially.  The nasal dorsum and sidewalls were anesthetized with 1% Lidocaine with 1:100,000 epinephrine.  The portion of the anterior turbinate was also anesthetized.  Total 3 mL was used.  Intercartilaginous incisions were opened. The soft tissue on the left was elevated off the bony dorsum.  Through the hemitransfixion incision, after the soft-tissue envelope was elevated, the bony pyramid was noted to have open-roof deformity, and there was prominence of the inferior portion of the bony pyramid bilaterally.  This was taken down with the downsizing chisels.  Medial osteotomies were performed through the hemitransfixion incision as the chiseling of the nasal dorsum exaggerated the open-roof deformity.    



The bony pyramid was still crooked pulling the septum off-center.  Lateral osteotomies were created through stab incisions anterior to the inferior turbinate.  The bony pyramid was freely mobile, was medialized.  With the bony pyramid free, the remaining portion of the septum seemed to come into midline.  The hemitransfixion incision was closed.  Silastic splints were placed on either side, secured with interrupted nylon suture.  Nasal cavity and nasopharynx were suctioned clear.  Inferior turbinate were reduced.  They were outfractured with Boies elevator then treated intramurally with the Elmed on a setting of 4, three passes each, going superior, middle, and inferior.  Intranasally, mupirocin ointment was place.  Nasal skin was cleaned, taped, and Thermasplint was placed.  The patient tolerated the procedures well and was awakened, extubated, and transferred to PACU for recovery.


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## b.cobuzzi (Jul 15, 2009)

30420
30240-50
30140-50-52 (if the elmed does cautery) or 30802 if the elmed does radiofrequency, i am unsure what function elmed does, I have never heard of it.  Doctor should do a better job of documenting the bilateral nature the turbinate reduction (it is reduction if elmed is cautery, reduction is outfracture and then cautery, it is radiofrequency, thus shrinkage, ablation, etc if elmed is radiofrequency).

It may be difficult getting the rhinoplasty portion paid, the payer may try and claim that this is a cosmetic procedure.  Do you have pictures to show how the acquired deformity is causing obstruction, do you have proof of how she acquired the deformity?  Did you get precertification for the septorhino?  You may have to fight for the septorhino, particularly the rhino portion and possibly even the septo portion, so be ready with proof of medical necessity and benefits.  Pictures really help!

Barbara J. Cobuzzi, CPC, CENTC


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