Otolaryngology Coding Alert

When you see "bony pyramid" and "mucoperichondrial flap," think "complete" and "septum" or you could land on a lesser-paying rhinoplasty code.

Spotting key terms in a rhinoplasty operative note could boost you from 30400's $1,003 range to 30420's $1,332 realm, using the 2008 unadjusted Medicare Physician Fee Schedule assignments and conversion factor of 38.0870.

Your medical terminology passes muster if you can pin down the correct CPT code in this abbreviated "Nasal and septal reconstruction with external approach" op note:

"Patient had nasal obstruction and septal deviation due to previous trauma.

"I made a columella incision and then rim incisions, elevating the skin and soft tissue envelope from over the lower lateral cartilages as well as the upper lateral cartilages and bony dorsum of the nose. Cut septum's caudal end to open the mucoperichondrial flap. Elevated the contralateral flap. Resected a portion of cartilage. From along maxillary crest, resected bony spur with an osteotome and forceps.

"After I corrected deformity all the way back to the vomer's perpendicular plate, I replaced the flaps and shaved a portion of the nose's bony dorsum with osteotomy. I made medial osteotomies and then lateral osteotomies and then reshaped the bony pyramid to alleviate the bony deformity ... I closed the flap with - "

First check whether the patient had previous nasal surgery or if this is the patient's first surgery in the area. The answer puts you in one of two code families.

For a first surgery, use the primary rhinoplasty codes:

If the patient has had a previous nasal surgery and this is a revision surgery (for instance, the patient's second or third surgery), report a secondary rhinoplasty. CPT classifies this procedure with three codes:

Solution: The above op note doesn't indicate a previous surgery or revision work. Therefore, you-re in the primary rhinoplasty code set (30400-30420).

Each ascending primary rhinoplasty code describes more work than the previous code. For instance, "30410 is more extensive than 30400," says Ben Willis, biller with Accurate Medical Billing in Tennessee.

Speed tip: To distinguish a 30400 op note from a 30410 description, scan the note for the word "pyramid." CPT defines a complete rhinoplasty as an operation that reshapes the external parts, including the bony pyramid.

Key: The above op report says, "reshaped the bony pyramid to alleviate the bony deformity." Therefore, the procedure is automatically beyond 30400.

When choosing between a primary and complete initial rhinoplasty, look for an op note describing 30410 to indicate the following additional work:

- reshaping the dorsum with a rasp

- fracturing the lateral nasal bones with chisels

- placing a splint or cast to support nasal tip cartilaginous surgery.

Our case shows that the otolaryngologist performed the first of these additional items. He "shaved a portion of the nose's bony dorsum with a rasp."

Pitfall: When you work on the bump, you will have a hard time convincing a payer that the procedure is not cosmetic work. You-ll have an easier time explaining that 30400 is functional because the procedure is more internal.

Code 30420 differs from the less extensive 30410 (32.00 relative value units) and 30400 (26.33 RVUs) in that 30420 involves major septal work. For 30420, the surgeon does all of 30410's work -- lateral and alar cartilages, and/or elevation of nasal tip -- plus external parts, including bony pyramid osteotomy and septoplasty, says Michael Setzen, MD, FACS, FAAP, clinical associate professor in otolaryngology at NYU School of Medicine and section chief of rhinology at North Shore University Hospital in Manhasset, N.Y.

The Coders- Desk Reference indicates that during 30420 (34.96 RVUs), the surgeon:

a. makes a vertical incision in the septal mucosa and elevates the mucoperichondrium from the septal cartilage

b. may remove or graft septal cartilage

c. fractures the nasal bones with chisels and manually repositions them in the desired positions

d. places an external splint or cast to support changes in bone position.

Compare the OR to this list. The final three sentences of the op note's second paragraph describe these items:

a. "Cut septum's caudal end to open the mucoperichondrial flap. Elevated the contralateral flap.

b. Resected a portion of cartilage.

c. From along maxillary crest, resected bony spur with an osteotome and forceps."

Although the surgeon did not use the words "fractures with chisels and manually reposition" to describe the fracture, paragraph two's final sentence and paragraph three's first part indicate this work. "Resected bony spur with osteotome" means he used a chisel-like instrument to break the bones (fracture). He then used the forceps to manually remove the bony spur. When he says, "After I corrected deformity all the way back to the vomer's perpendicular plate," he indicates he repositioned the bones.

Best practice: For clarity, you could encourage your otolaryngologist to use "fracture" or "break," instead of "resect." The latter term incorrectly suggests that the surgeon removed bone, rather than breaking it, which can cause you to select an inappropriate CPT code.

Be careful: Do not use fracture repair codes 21325-21336 instead of rhinoplasty codes just to make the payment path easier. Reserve 21325-21336 for when the surgeon truly treats a fracture, not a late fracture as with functional rhinoplasty.