# Nasal valve collapse coding help



## juneh (Jan 11, 2010)

*1st I am new to posting! I appreciate all the help that has been provided, Thank You! Ok *I need help, Operative report reads......
The patient is taken to the operating room suite and placed supine on the operating room table.   Per the Department of Anesthesia, the patient is administered general inhalation anesthesia.  The patient is prepped and draped in the usual fashion.


1% lidocaine is injected along the nasal valve with the protrusion of cartilage, the anterior to posterior nasal septum.  Cottonoid pledget impregnated with Afrin are placed into each  nasal cavity.  The patient is sterilely prepped and draped in the usual fashion.   Cottonoids are removed.  The procedure is commenced. 


The patient has had previous septorhinoplasty fairly aggressive work.   There are incisions in front of the nose and scarring and remodeling of bone and cartilage anteriorly but the patient does have a septal deviation off to the right that is bony and goes into the nasal cavity which obstructs anteriorly for the patient.   Additionally, she has these protrusions of the lower lateral cartilages.  I am not sure if they were flipped or exactly what was done with the rhinoplasty but it is unusual because this cartilage protrudes into the nasal cavity bilaterally creating obstruction as she breathes in and collapses down up against the septum.  This is worse on the right side than the left.   These things will be addressed first.



Initially, a right-sided anterior nasal septal Cottle incision is made down to the mucoperichondrial plane.   This is a very difficult plane as there is a lot of scar tissue here.  This is elevated off of the bony spurs and deviated portions.   The contralateral plane is elevated and then a small chisel and Takahashi forceps are utilized to remove the spurs and the deviated portion of the bone and cartilage until that frees up.   The  mucoperichondrial planes are laid back in their natural orientation, sewn together with a 4-0 chromic suture.  



The nasal valve is subsequently addressed and again this is done bilaterally.   Adjacent to where the cartilage protrudes into the nasal cavity, a Beaver Blade is utilized to make an incision above this cartilage and then dissection is carried down with iris scissors to delineate the extent of the cartilage which protrudes into the nasal cavity.  This cartilage is then excised and removed with the iris scissors.   There is some skin that is trimmed on the right side; in particular because once that cartilage is removed, there is excess skin and this is trimmed so it can be laid back in a more natural orientation.   4-0 gut suture is utilized to reapproximate the skin.  This does improve the anterior nasal valve area nicely and should help her with overall breathing.  

Docs coded 30465, I considered 30420 or just 30520...Any help greatly appreciated. 
June H Ocala Fl


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