# staged revision???



## KELLI (Jun 16, 2011)

I am not sure how I should code this?? It does not seem to fit under a rhinoplasty.. Should I just code the grafts and W-plasty??

PREOPERATIVE DIAGNOSIS:  Nasal deformity from CPAP injury with
necrosis of columella.

POSTOPERATIVE DIAGNOSIS:  Nasal deformity from CPAP injury with
necrosis of columella.

PROCEDURE PERFORMED:  Staged revision of forehead flap with cartilage
grafting to nasal tip, W-plasty inset, reconstruction of soft
triangle and columella, and reduction of columella flap.


DESCRIPTION OF PROCEDURE:  Under general anesthesia, the patient was
prepped and draped in the usual sterile fashion.  Marcaine with
epinephrine was injected to the left ear.  A postauricular incision
was made.  Previous ear cartilage has been harvested from this ear,
but there is residual cartilage left.  So, rather than harvest from
the contralateral ear, the remaining cartilage was needed was
harvested from the conchal bowl.  After the conchal bowl cartilage
was harvested, it was wrapped in a saline-soaked gauze and preserved.
 Meticulous hemostasis was obtained and the postauricular incision
was closed with Histoacryl and chromic sutures.  A Glasscock splint
was then placed at the end of the case.

Attention was then directed to the columella where, after the
injection was given, an indentation in the columella where there was
a disjunction between the forehead flap and the remainder of the nose
was identified.  A W-plasty incision was made in this area to open to
tip to allow for joining these areas.  Cartilage grafting to the
columella and then the domes was then performed. The cartilage was
sewn in place with 5-0 PDS suture.  This included a soft triangle of
cartilage in this area.  Once the soft triangle was created, the
W-plasty incisions were then inset, eliminating the large defect that
was present with the indentation in this area.  Laterally, because of
bulkiness of the columella with a hanging columellar deformity, the
graft was debulked and then sewn laterally into the lateral part of
the columella.  This tightened the columella and got rid of the
hanging deformity.  This was sewn with multiple resorbable sutures.

At the end of the case, nasal splints were placed with no pressure on
the nose, with extreme care taken to place no pressure on the
columella so as not to cause any problems with vascular liability.

The patient tolerated the procedure well with no complications.  The
patient was sent to recovery in good condition.


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## Jan CPC I (Jun 16, 2011)

*Flap revision*

Here is how I see it...

DESCRIPTION OF PROCEDURE: Under general anesthesia, the patient was
prepped and draped in the usual sterile fashion. Marcaine with
epinephrine was injected to the left ear. A postauricular incision
was made. Previous ear cartilage has been harvested from this ear,
but there is residual cartilage left. So, rather than harvest from
the contralateral ear, the remaining cartilage was needed was
harvested from the conchal bowl. After the conchal bowl cartilage
was harvested, it was wrapped in a saline-soaked gauze and preserved.
Meticulous hemostasis was obtained and the postauricular incision
was closed with Histoacryl and chromic sutures. A Glasscock splint
was then placed at the end of the case.[

*For the above paragraph, I suggest 21235 for the harvest of the cartilege graft *

Attention was then directed to the columella where, after the
injection was given, an indentation in the columella where there was
a disjunction between the forehead flap and the remainder of the nose
was identified. A W-plasty incision was made in this area to open to
tip to allow for joining these areas. Cartilage grafting to the
columella and then the domes was then performed. The cartilage was
sewn in place with 5-0 PDS suture. This included a soft triangle of
cartilage in this area. Once the soft triangle was created, the
W-plasty incisions were then inset, eliminating the large defect that
was present with the indentation in this area.

*For the above paragraph I suggest 30430 or 30400 (depending on primary or secondary). The W-plasty is only made here to lift the nose open to work on it and for a better cosmetic result when the nose is closed, and should not be reported separately *

Laterally, because of bulkiness of the columella with a hanging columellar deformity, the
graft was debulked and then sewn laterally into the lateral part of
the columella. This tightened the columella and got rid of the
hanging deformity. This was sewn with multiple resorbable sutures.

*If the original code for previous surgery was  the forehead flap 15731, and if the flap mentioned in this last paragraph above is the flap the provider is debulking then you could use 14060 for the debulking per parenthetical guideline on page 73 of 2011 CPT book underneath the code 15650.  Of course, this is without having read the original surgery*. 

For ICD's I would use acquired deformity of the nose, with an injury code to reflect the indication for the surgery. 

Of course, these are only suggestions, but it is how I see it. I hope this helps...


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