Otolaryngology Coding Alert

Question: My doctor says “a fracture is a fracture forever.” The patient presented with a crooked nose that needed straightening out. That’s why our physician does nasal bone fracture repairs — it doesn’t matter if the fracture is acute or old. He says he has to rebreak the nose with acute fractures.

The patient has had two nasal fractures in the past, one in 1989 and another one several years ago, both of which were repaired at the time of injury. Our physician wants to operate and do an open reduction of the nasal fracture, nasal valve repair, revision septoplasty, inferior turbinate reduction, and then cartilage graft.

Can I consider this a nasal fracture this far out? Is it a septorhinoplasty? The previous fractures have healed by now. Could you help?

Kentucky Subscriber

Answer: An acute nasal fracture is a diagnostic condition and not a description of what the surgeon is doing to the patient’s nose. The surgeon needs to carefully parse the CPT language when the narrative contains diagnostic language. For example, the descriptor “Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation” has both diagnosis and procedure language specified. 

An acute comminuted nasal fracture may be allowed to partially heal prior to a primary repair, but this is a matter of days — a week or two. After that, the nasal bones won’t readily move back into place and will require osteotomies (i.e. the surgeon is now doing the fracturing, not the baseball or so on).

From a coding standpoint: This surgeon is dealing with the sequela, a condition that is the consequence of the previous acute injury to the nose. ICD-10 actually provides diagnostic codes specifying sequela conditions versus an acute status.

You should code the treatment of healed fractures and the sequelae of trauma using the rhinoplasty code series. For instance, 30410 (Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip) describes a surgical procedure to alter the bony portion of the nose as well as the cartilaginous portions covered in code 30400 (Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip).

In airway obstruction surgery, the physician attempts to correct asymmetries, weakness or distortions in all three portions of the nose. In functional cases, the nasal bone(s) and/or cartilages are shifted or depressed to previous trauma, causing a fixed narrowing of the interior nasal passage and a marked reduction in airflow. Nasal valve collapse may be the result of previous trauma or weakening with age. The nasal valve usually refers to the slit-like opening between the caudal end of the upper lateral cartilage and septum, the narrowest portion of the upper airway. Minimal constriction in this area causes substantial restriction in airflow and even a small degree of improvement is extremely beneficial in correction airway obstruction inside the nose. Severe ptosis of the nasal tip or alar collapse may compromise breathing.

Functional cases very often require cartilage and/or bone grafts to augment the structural support of the nose. The exact placement and fixation of these various grafts can require a significant amount of work beyond the usual primary rhinoplasty. Cosmetic rhinoplasty (i.e. solely for the improvement of contour and appearance) most often involves the opposite strategy: reduction of the bony and cartilaginous framework in the absence of external asymmetry.

Incidental procedures to 30410 would include application of vasoconstrictor; removal of caudal (anterior) end of septum to rotate tip; placement of grafts; superficial or intramural cauterization and/or ablation of turbinate mucosa; control of operative bleeding; closure of surgical incisions; removal of sutures, dressing, stents and/or splints; uncomplicated postop follow-up evaluation and management services.

Separately identificable procedures include obtaining only autogenous bone , costochondral cartilage, nasal septal cartilage, ear cartilage, temporalis fascia, or composite grafts; excision, submucous resection, or therapeutic fracture of turbinates; documented initial diagnostic assessment.

Watch out: Physicians (and coders) typically misuse the fracture diagnosis and fracture procedure codes outside of the acute fracture period because third party payors didn’t screen them. The services are covered under policy provisions for accident/injury benefits and would require the date of injury on the claim. Also, they would perhaps require coordination of benefits with liability insurance. Using the appropriate diagnostic codes (e.g. nasal obstruction or malunion of fracture or acquired nasal deformity or late effect of facial bone fracture) or procedure codes (30400 series) often meant a pended or denied claim because many third party payers treat the 30400 series of codes as cosmetic procedures only. These claims would usually be paid upon review, but the wait was long and the reimbursement always a significant disappointment to the surgeon involved. 

This particular surgeon’s views on surgical indications and treatment are mainstream. It’s just a matter of coding. 

Also, keep in mind, a properly documented and pre certified functional and medically necessary rhinoplasty or septoprhinoplasty actually pays more than a fracture reduction code. So, not only is the coding more correct, but coded and documented correctly, it pays more. However, you often have to fight for the medical necessity and need to prove it is not a cosmetic procedure.