# rhinoplasty with septoplasty



## BFAITHFUL (Apr 21, 2009)

please take a look at the following op report, our dr wants to bill both 30400 & 30520???    but I'm just not sure, plastics are really my weakest area!


clinical history:  
19yr old has had a serious injury to his nose, when he alledgedly struck his nose on a pool, patient has elected to have the nose resected in the distal course which was severely deviated.  the inferior turbinates, which are necessarily obstructing the airway reduced the overhaning bone and then, the septum, which has a S-shaped deviation, also externally deviating more to the right side direct with a combination of resection, implantation of internal nasal splints, and scarring of the deviated segments.  the patient will have also the bony defect addressed with resection ofthebony dorsum as the septum was reduced.

Operative procedure:
the patient was placed on the operating table,  prepping and draping of the head and neck area was done in the usual manner with betadine.  cocaine was used intranasally and 1% xylocaine in the skin.  Once this was accomplished, the patient had a transmembranous incision made at the most caudal distal septum, which was totally deviated and the area was completely resected.  This had been permitted the ability to examine the inferior turbinates and both were reduced 50% dorsal from the overhaning bone with a combination of cautery and resection.  The patient then had careful mucoperichondrial flaps raised and the synechia, which was extending up until theleft airway release of the superior turbinate with a Goldman elevator.  The most serious deviation of the septum was resected.  The remaining area was then kept in  position with in situ morselization.  The septal flaps were corrected with 3-0 Vicryl and the septum was now midline.  The patient still had a remaining deformity external, and this was resected with a 8mm osteotome.  The patient at this point still had some collapse of the intranasal valve and some of the caudal septum after being resected back the area was draped.  Then had a graft taken from the septum and secured with 4-0 Vicryl, which raised the tip and the lower base of the nose approximately 4mm.  This also gave the external nasal valve a better nasal port airway breathing as the patient had vertically obstruction from  combination of caudal septal deviation, deviation further up in the septum, and the inferior turbinate hypertrophy.  at this point, the nose which was asymmetric or symmetric.  the patient had good nasal airways then bilaterally.  the nasal bones were carefully repositioned back to midline and the nasal dorsal skin secured with multiple sutures of 3-0 chromic and 5-0 chromic and 5-0 chromic.

thanks for your help!   I also believe we can bill 30130-50


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## jackjones62 (Apr 22, 2009)

First question, did your physician repair bilateral internal nasal valves? I could not tell reading the operative report; based on what I read, I would suggest the following:

CPT 30465 Repair of nasal vestibular stenosis (nasal valve repair-this is a bilateral proc., if done unilaterally, use mod. 52, CCI edits-30520 & 30400)
CPT 20912 Cartilage Graft; nasal septum
CPT 30140 Submucus resection inferior turbinates

From what I read, it appears most of the work involved the septum and nasal valve(s); with regards to a "rhinoplasty" (30400), I do not feel that the one reference where the surgeon addressed the external deformity by resecting it with an 8mm osteotome supports a rhinoplasty code.

Jennifer
ENT CT


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