Otolaryngology Coding Alert

Repairing a perforated septum is a complex and time-consuming procedure. The CPT code used to bill for septum repair, 30630 (repair nasal septal perforations), has been assigned 16.96 relative value units (RVUs), or approximately $600, depending on where the procedure is performed. Some otolaryngologists believe this amount does not compensate adequately for what can be a three-to four-hour procedure.

If the perforation being repaired is large, however, any additional flaps or grafts may be coded in addition to the basic perforation repair, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs editorial panel and executive committee.

Finding the right codes for these operative sessions can be tricky because several different procedures may be billed, depending on the size and location of the perforation, as well as surgeon preference, says Eisenberg. He adds that coding and billing issues should be discussed ahead of time and received in writing from the carrier in question.

Cause and Treatment of Septal Perforations

Septal perforation can be caused by trauma, such as nasal picking or septal surgery (i.e., septoplasty or submucous resection of septum), as well as by septal abscess after a hematoma and granulomatous diseases. Abuse of cocaine or decongestant nasal sprays also may lead to septal perforation because both drugs are vasoconstrictors that diminish blood flow to the perichondrium, which covers the septum and provides its blood supply.

Such perforations can cause a variety of problems. For example, as mucous gets into the hole, its size diminishes, and may cause intermittent whistling. Some patients have crusting, which can lead to airway obstruction. Other symptoms can include discharge and epistaxis. In extreme cases, the perforation can cause the nose to collapse.

Although minor symptoms can be treated at home, using saline douches and ointment on the edges to diminish crusting, surgical repair of the perforation may be necessary. According to the Coders Desk Reference (CDR), this involves the creation of local mucoperichondrial flaps on either side of the perforation with a scalpel. Each flap is designed to expose one side of the septal cartilage while retaining mucosal coverage of the septal cartilage of the opposite side. The flaps are sutured in a single layer to cover the perforation.

If the perforation is larger than 1 cm, Eisenberg says, additional tissue may be required to enhance the repair. The flaps described in CDR are elevating local tissue, much like a regular closure. But with a large perforation, that may not be sufficient, he says. The additional tissue may be in the form of temporal fascia grafts or pedicle flaps, and such additional procedures are payable separately, according to the CDR.

How to Code the Procedures

Depending on the size and location of the perforation, the repair of the septum can be performed in several different ways, Eisenberg says. For example, a small perforation simply would be coded 30630. If temporalis fascia is obtained and used to close the perichondrial mucosa on both the right and left sides, code 15770 (graft, derma-fat-fascia) may be billed separately. If cartilage was harvested to close the septum itself, code 21235 (graft; ear cartilage, autogenous, to nose or ear [includes obtaining graft]) also may be billed.

Note: CPT code 20912 (cartilage graft, nasal septum) refers to the source of the graft. When the nasal septum is the anatomic site requiring the repair, 20912 should not be used because the septum cannot be both the donor and recipient sites.

Alternatively, Eisenberg says, the surgeon may use buccal mucosa from the inside of the patients cheek to created a direct pedicle flap, which would be coded 15576 (formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral). If this procedure is done, a subsequent delay of flap will be performed, and would be coded 15630 (delay of flap or sectioning of flap [division and inset]; at eyelids, nose, ears, or lips). Because the delay of flap is a staged procedure, it should be appended with modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to indicate it was planned and is not included in the original procedures global period.

If tissue is taken from the floor of the nose or from a turbinate, it may be appropriate to use code 14060 (adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq. cm. or less), Eisenberg says. He notes that given the variety of codes that might describe the procedures performed, the operative report should be studied carefully to make sure what was billed actually matches the documentation in the procedure notes.

If the correct graft or flap codes cannot be selected, the carrier may accept and, given the complex nature of these codes, may even welcome the original 30630 alone with modifier -22 (unusual procedural service). This will prompt a review of the documentation to indicate that the 30630 repair was more complicated and took significantly more time than usual (due to the additional grafting performed).

As always, when modifier -22 is used, the documentation must indicate the complex and unusual nature of the procedure, and also should document both the typical time spent during this procedure and the amount of time the procedure in question actually took. A short paragraph also may be helpful in explaining to the carrier why additional payment is being sought.

Whenever possible, carriers should be contacted ahead of time for their views on how this complicated coding scenario should be billed, Eisenberg says. Septal perforation repair usually is scheduled in advance, and although contacting the carrier before the procedure is performed is no guarantee of payment, it helps to work it out with the carrier ahead of time. These scenarios are complicated for the carrier too, so many are happy to figure it out beforehand.

Related Codes

If the perforation or defect is too large to repair, the otolaryngologist may use an alloplastic button to obturate, or close, a nasal septal opening. This procedure, which creates a new wall between the nostrils, is performed as an option to surgical reconstruction of the septum, according to CDR, by inserting a silicone rubber button into the septal perforation and securing it with transseptal sutures. The insertion of the septal button, which can be performed in the otolaryngologists office, has a 10-day global period and is a lesser paying procedure, with a value of only 3.72 RVUs.

Although some otolaryngologists report using code 30620 (septal or other intranasal dermatoplasty) for septal defects or perforations, this rarely performed procedure applies only to patients with recurrent epistaxis associated with hereditary telangiectasia, according to Laurel Ferris, MA, an independent facial plastic coding and reimbursement specialist in Edina, Minn., and author of Facial Plastics Code-a-Graphics, an illustrated guide for coding facial plastic surgery distributed by the American Society of Plastic and Reconstructive Surgeons.

Usage of [30620] to indicate any and all intranasal procedures that improve airway function is not appropriate; it no longer refers to functional nasal reconstruction. Use a different code instead, if performing ... repair of septal perforation[s] (30630), Ferris writes.

Note: Suzanne Yee, MD, a facial plastic surgeon in Little Rock, Ark.; and Randa Blackwell, a coding specialist with the department of otolaryngology at the University of Maryland in Baltimore, also contributed to this article.