Otolaryngology Coding Alert

Your answers to this nose repair could capture $1,247 in pay.

You-ve got to nail down when a nasal fracture repair turns into a rhinoplasty, or you could miss pre-certifying the rhinoplasty as a medically necessary procedure.

Here's your scenario: A patient has a history of trauma to his nose that has resulted in severe deformities and he has trouble breathing. Your ENT decides it's time to rebuild the nose extensively. Even though the procedures could cause blindness and cerebrospinal fluid leak, the patient agrees.

In the following subscriber-submitted op note, the ENT is treating a patient who has trouble breathing due to trauma and scarring to the nose. But it's not a recent break; troublesome scar tissue has formed and deformed septal cartilage resists straightening.

The office where Julie Keene, CPC, CENTC, works has been in a debate over a similar case.

"We haven't come up with the final answer yet, but I can tell you that we are leaning toward coming up with a time frame for fracture repairs," says Keene, an otolaryngology coding and reimbursement specialist for University Ear, Nose and Throat Specialists Inc. in Cincinnati.-

"Fractures can take up to six months to heal, or longer depending on whom you ask," Keene says.-"I have asked that the cutoff be six months or less and then it becomes a rhinoplasty."

"The rule of thumb I was always taught was patients needed to be operated on within 21 days (of a fracture), or the bones have to be rebroken, in most cases," Keene says. "While that still holds true, physicians still consider it a fracture repair if the patient does not get it repaired within a month." Surgeons often want the bones to heal and the swelling to go down before they attempt to repair the damage.

"I also believe that if the CT scan shows no fracture then it is a rhinoplasty," Keene explains.

Because rhinoplasty also describes elective cosmetic work, insurers insist you pre-certify procedures coded in the 304xx range. If you miscode a rhinoplasty as a fracture fix, you-re liable to face a denial.

Diagnosis: "This individual has had difficulty with nasal airway obstruction and nasal deformity with chronic intermittent left maxillary sinusitis," the op note says. Your ENT recommends nasal reconstruction using open technique due to the severe twisting and deformity of the nasal dorsum and the trauma the patient has suffered in the past. Your ENT will perform a left nasal antral window with removal of a cyst, too.

Our experts say that translates into these diagnosis codes:

- 473.0 -- Chronic sinusitis; maxillary

- 905.0 --Late effect of fracture of skull and face bones

- 738.0 -- Acquired deformity of nose

- 478.0 -- Hypertrophy of nasal turbinates

- 478.49 -- Other diseases of nasal cavity and sinuses

- V15.51 -- Other personal history presenting hazards to health; traumatic fracture.

One diagnosis code will be helpful for a patient who needs a rhinoplasty (such as 30400, Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip) to repair the nose after a car accident or in other situations. Although you normally complete a pre-determination anyway, it's nice to have more accurate diagnosis codes.

- You can now indicate the patient has a history of traumatic fracture with V15.51.

- "Though a history of a traumatic fracture may not put a patient at increased risk for future fractures, the fact that a bone was traumatically fractured in the past may also affect future treatment," according to the agenda notes from the ICD-9-CM Coordination and Maintenance Committee Meeting on March 22-23, 2007.

Do this: Add V15.51 to your options when treating patients for medical conditions linked to previous fractures. Group it with 905.0 and 738.0 to give the insurer additional information that the patient had a previous nasal fracture, and that the current problem is directly linked to it.

With the patient under general anesthesia, the ENT makes incisions. "The dissection was taken over the lower lateral cartilages to the septum," the op note says. The ENT uncovers the deformity that's causing the patient's trouble: "A significant obstruction of the right nostril due to the extensive deviation and deflection of the septum in this region." Further dissection on both sides of the nose reveals "a marked, severe, deflection into the left nostril and into the medial portion of the nose."

The ENT cuts a tunnel on the left side of the nose, and remarks that he must "separate the bony-cartilaginous junction - before further dissection could be accomplished medially due to the irregularities and deformity of the nose." The ENT uses forceps "to remove the bony portion, which was causing obstruction on the left side."

The surgeon then cuts out a "window of cartilage" to make spreader grafts, which he places on both sides of the patient's nose. Another graft overlaps the cartilage on the left side.

The ENT moves on to repair the patient's crura, cartilage that gives the nostrils their shape. "The medial crura were badly deformed and twisted and had no significant support," the op note says. "This deformity had obviously occurred after scarring had taken place."

The ENT places a "substantial" piece of cartilage between the medial crura, "but the septum continued to extend into the right nostril, and it was not possible to break the memory of the cartilage to have it come back over to the midline." The ENT amputates the caudal end of the septum "so that it did not continue to cause distortion of the tip and obstruction."

He sutures the graft to the medial crura and sutures the septal remnant extending on the right. The ENT then cauterizes the inferior turbinates and reduces the bones underneath the mucosa with Boise elevators on both sides before sewing the wound closed.

The ENT switches to a 30-degree endoscope with a shaver to gain entry to the left maxillary sinus. He uses the shaver and forceps to remove the cyst. The ENT packs and splints the wounds and ends the procedures.

Resist the temptation to code this as a nasal fracture repair. The ENT is repairing deformities that arise from old trauma, not a freshly broken nose. You-ll use 30420 (... including major septal repair) for the main procedure.

A reduction of a nasal fracture is a procedure where the nasal bones are repositioned in straighter alignment. Often the nasal septum (the dividing wall inside the nose) is knocked out of alignment by the fracture and also needs to be straightened out. That procedure is called a septoplasty.

Describe the cutting and preparation of the "window of cartilage" with 20912 (Cartilage graft; nasal septum).

Use 30930-50 (Fracture nasal inferior turbinate[s], therapeutic) to describe the fracture and cautery of the inferior turbinates. Append modifier 50 (Bilateral procedure) to show that the surgeon reduced turbinates on both sides. Don't report 30801 (Cautery and/or ablation, mucosa of inferior turbinates, unilateral or bilateral, any method; superficial) for the superficial cautery. Code only the highest turbinate code (30930-50), not both.

"Ninety-nine percent of the time when I go in to do auditing, I find turbinate codes done wrong," says Joanne Schade-Boyce, RDH, MS, CPC, vice president of FairCode Associates in Germantown, Md.

When a physician talks about "reduction of turbinates," it usually means a combination of procedures -- for example, removing submucosal tissue and "outfracturing" the inferior turbinate bones -- to open up air passages, Schade-Boyce says.

For the cyst removal, use 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus).

Op notes involving the nose and sinuses can get confusing in a hurry. "You-ve got to have a good anatomy book," Schade-Boyce says.