rgeib
Networker
So I'm debating which way to go on the following (most relevant sections have been highlighted):
PREOPERATIVE DIAGNOSIS: Nasal deformity.
POSTOPERATIVE DIAGNOSIS: Nasal deformity.
OPERATION: Revision of septorhinoplasty with septal cartilage
grafting.
The patient was taken to the operating room, placed on the
operating table in a supine position and sedated and placed under
general anesthesia. An IV tube was placed and secured to the
midline lower lip position. Total IV anesthesia was used for this
procedure. The bed was turned 90 degrees from Anesthesia for the
procedure. A surgical time-out was performed and the consents were
verified. The patient was prepped and draped in a sterile fashion
for this procedure. The nose was topically decongested with
Afrin-soaked nasal pledgets. The nose was then injected with local
anesthesia consisting of 1% lidocaine with 1:100,000 concentration
of epinephrine. After allowing several minutes for the epinephrine
and local anesthesia to take full effect, procedure began with
septal cartilage harvest. A complete transfixion incision was made
and extended down below the level of the medial crural footplate
attachment to the septum in order to help with some tip
de-projection. A subsequent left-sided mucoperichondrial flap was
then raised exposing the nasal septal cartilage. Great care was
taken to maintain the integrity of the mucoperichondrial flap at all
times. A chondrotomy was then made 2 cm posterior to the caudal
edge of the nasal septum and a subsequent right-sided
mucoperichondrial flap was then raised exposing the quadrangular
cartilage of the nasal septum where a rectangular portion of the
quadrangular cartilage was harvested to be used for grafting
purposes, which extended 2 cm caudal to the nasal septum,
posteriorly to the bony cartilaginous junction leaving a minimal 2
cm x 2 cm L strut of cartilage dorsally and caudally. Additionally,
portion of the removed cartilage was crushed in a caudal crusher and
then replaced between the mucoperichondrial flaps prior to coapting
the flaps together with a 4-0 plain gut suture in a whipstitch
fashion. The incomplete transfixion incisions were then closed with
interrupted 5-0 chromic sutures. A slight 1 to 2 mm tip
de-projection was achieved with a complete transfixion incision by
extending it down below the level of the medial crural footplate
attachment to the nasal septum disrupting this major tip support.
Next, an open rhinoplasty approach was performed. A mid columellar
inverted V incision was marked. Incisions were then made along the
lateral portion of the columella, which were joined to the mid
columellar incision and further incisions along the caudal edge of
the lower lateral cartilages were carried up in the standard open
rhinoplasty fashion and using both sharp and blunt dissection, the
skin and soft tissue envelope was dissected off the lower lateral
cartilages. The nasal tip cartilages were noted to be intact and
slightly asymmetric. The lateral crus of both lower lateral
cartilages was aggressively previously resected with less than 3 mm
of lateral crus remaining bilaterally. Significant subcutaneous
scar tissue was encountered and wide dissection of the skin and soft
tissue envelope was performed. Dissection continued onto the
cartilaginous dorsum proceeding up to the bony dorsum where a
transition to subperiosteal dissection was performed. Wide
undermining of the skin and soft tissue envelope was performed in
order to help release any scar tissue contracture. The mid vault
area was noted to be weakened and in order to address this and
strengthen the mid vault and the dorsal cartilaginous septum,
bilateral spreader grafts were used. The upper lateral cartilages
were separated from their attachments to the dorsal nasal septum and
spreader grafts which extended from the caudal edge of the nasal
bones to the anterior septal angle were shaped from the previously
harvested quadrangular cartilage and secured to the midline septum
on either side with 5-0 PDS mattress sutures. This was followed by
re-suspension of the upper lateral cartilages to the spreader grafts
into the dorsal nasal septum with additional 5-0 PDS sutures. This
allowed for straightening and support to the mid vault region.
Next, attention was drawn toward improvement to the concavities to
the supra-alar region, which was noted to be secondary to aggressive
resection of previous lateral crura. In order to address this
situation, a lateral crural onlay graft technique was used. Grafts
carved from the previously harvested septal cartilage were used,
which extended from just posterior to the nasal dome to the entire
length of the lateral crus bilaterally and was secured to the
remnant of the lateral crura bilaterally with 5-0 PDS sutures. This
allowed for improved support to the lateral crura as well as
correcting the deep conchae cavity to the supra-alar region. The
edges of the grafts were beveled appropriately in order to prevent
any irregularities showing through the skin. Next, attention was
drawn toward the nasal tip and dome region, where the slight
asymmetry was corrected with tip suturing to include single and
double dome sutures. A small soft tissue graft was placed over the
nasal domes in order to help prevent against any irregularities
given the patient had relatively thin skin. Next, in order to
firmly establish his tip height as well as rotation,
tongue-in-groove technique was used where the medial crura and
medial crural footplates were separated from their attachments,
mobilized, and then secured to the caudal septum with 5-0 PDS
sutures positioning them allowing for adequate tip position and
rotation. The skin and soft tissue envelope was then redraped over
the bony cartilaginous frame and once again, the patient was checked
for adequate tip support, symmetry, as well as rotation and
projection. Fine adjustments were made accordingly. Next, the
incisions were then closed with mid columellar incision closed with
interrupted 6-0 Prolene sutures. The marginal incisions were closed
with interrupted 5-0 chromic sutures. The lateral columella portion
incisions were closed with interrupted 6-0 fast-absorbing gut
sutures.
Attention was then drawn toward the nasal base and reduction of the
patient's nostril flare. This was performed through modified Weir
excisions. A marking pen was used to mark crescent shaped incisions
along the nasal facial junction extending into the nasal alar base
with great care taken not to disrupt the natural boundary between
the nasal alar junction. Local anesthesia was then used to inject
these areas. A #11 blade was then used to excise a portion of the
nasal ala and extending into the nasal base. This allowed for an
advancement rotation flap essentially to reduce the nasal alar base.
3 mm of alar were removed bilaterally. The incisions were then
closed with combination of interrupted 5-0 PDS sutures followed by
vertical mattress sutures of 5-0 Prolene extranasally and intranasal
vertical mattress sutures using 5-0 plain gut sutures. The patient
was again checked for adequate symmetry and support prior to
completion. Telfa tacos coated in bacitracin ointment were placed
in the left and right nasal cavity to be removed by the patient on
postoperative day 1. This completed the procedure. The patient was
then turned back to Anesthesia, where he was awakened, successfully
extubated, and taken to the recovery room in stable condition. He
tolerated this procedure well without complications.
My original thinking was to just code 30420 for septorhinoplasty, but as this is stated to be revision surgery, should I be coding from 30410-30430 along with 20912 for the septal graft? Typically, I never code septal grafts separately, but I'm not sure here since it was obtained through a separate incision. Also, should I be coding for the mentioned nasal ala rotation flap? Any help would be appreciated. Thanks.
PREOPERATIVE DIAGNOSIS: Nasal deformity.
POSTOPERATIVE DIAGNOSIS: Nasal deformity.
OPERATION: Revision of septorhinoplasty with septal cartilage
grafting.
The patient was taken to the operating room, placed on the
operating table in a supine position and sedated and placed under
general anesthesia. An IV tube was placed and secured to the
midline lower lip position. Total IV anesthesia was used for this
procedure. The bed was turned 90 degrees from Anesthesia for the
procedure. A surgical time-out was performed and the consents were
verified. The patient was prepped and draped in a sterile fashion
for this procedure. The nose was topically decongested with
Afrin-soaked nasal pledgets. The nose was then injected with local
anesthesia consisting of 1% lidocaine with 1:100,000 concentration
of epinephrine. After allowing several minutes for the epinephrine
and local anesthesia to take full effect, procedure began with
septal cartilage harvest. A complete transfixion incision was made
and extended down below the level of the medial crural footplate
attachment to the septum in order to help with some tip
de-projection. A subsequent left-sided mucoperichondrial flap was
then raised exposing the nasal septal cartilage. Great care was
taken to maintain the integrity of the mucoperichondrial flap at all
times. A chondrotomy was then made 2 cm posterior to the caudal
edge of the nasal septum and a subsequent right-sided
mucoperichondrial flap was then raised exposing the quadrangular
cartilage of the nasal septum where a rectangular portion of the
quadrangular cartilage was harvested to be used for grafting
purposes, which extended 2 cm caudal to the nasal septum,
posteriorly to the bony cartilaginous junction leaving a minimal 2
cm x 2 cm L strut of cartilage dorsally and caudally. Additionally,
portion of the removed cartilage was crushed in a caudal crusher and
then replaced between the mucoperichondrial flaps prior to coapting
the flaps together with a 4-0 plain gut suture in a whipstitch
fashion. The incomplete transfixion incisions were then closed with
interrupted 5-0 chromic sutures. A slight 1 to 2 mm tip
de-projection was achieved with a complete transfixion incision by
extending it down below the level of the medial crural footplate
attachment to the nasal septum disrupting this major tip support.
Next, an open rhinoplasty approach was performed. A mid columellar
inverted V incision was marked. Incisions were then made along the
lateral portion of the columella, which were joined to the mid
columellar incision and further incisions along the caudal edge of
the lower lateral cartilages were carried up in the standard open
rhinoplasty fashion and using both sharp and blunt dissection, the
skin and soft tissue envelope was dissected off the lower lateral
cartilages. The nasal tip cartilages were noted to be intact and
slightly asymmetric. The lateral crus of both lower lateral
cartilages was aggressively previously resected with less than 3 mm
of lateral crus remaining bilaterally. Significant subcutaneous
scar tissue was encountered and wide dissection of the skin and soft
tissue envelope was performed. Dissection continued onto the
cartilaginous dorsum proceeding up to the bony dorsum where a
transition to subperiosteal dissection was performed. Wide
undermining of the skin and soft tissue envelope was performed in
order to help release any scar tissue contracture. The mid vault
area was noted to be weakened and in order to address this and
strengthen the mid vault and the dorsal cartilaginous septum,
bilateral spreader grafts were used. The upper lateral cartilages
were separated from their attachments to the dorsal nasal septum and
spreader grafts which extended from the caudal edge of the nasal
bones to the anterior septal angle were shaped from the previously
harvested quadrangular cartilage and secured to the midline septum
on either side with 5-0 PDS mattress sutures. This was followed by
re-suspension of the upper lateral cartilages to the spreader grafts
into the dorsal nasal septum with additional 5-0 PDS sutures. This
allowed for straightening and support to the mid vault region.
Next, attention was drawn toward improvement to the concavities to
the supra-alar region, which was noted to be secondary to aggressive
resection of previous lateral crura. In order to address this
situation, a lateral crural onlay graft technique was used. Grafts
carved from the previously harvested septal cartilage were used,
which extended from just posterior to the nasal dome to the entire
length of the lateral crus bilaterally and was secured to the
remnant of the lateral crura bilaterally with 5-0 PDS sutures. This
allowed for improved support to the lateral crura as well as
correcting the deep conchae cavity to the supra-alar region. The
edges of the grafts were beveled appropriately in order to prevent
any irregularities showing through the skin. Next, attention was
drawn toward the nasal tip and dome region, where the slight
asymmetry was corrected with tip suturing to include single and
double dome sutures. A small soft tissue graft was placed over the
nasal domes in order to help prevent against any irregularities
given the patient had relatively thin skin. Next, in order to
firmly establish his tip height as well as rotation,
tongue-in-groove technique was used where the medial crura and
medial crural footplates were separated from their attachments,
mobilized, and then secured to the caudal septum with 5-0 PDS
sutures positioning them allowing for adequate tip position and
rotation. The skin and soft tissue envelope was then redraped over
the bony cartilaginous frame and once again, the patient was checked
for adequate tip support, symmetry, as well as rotation and
projection. Fine adjustments were made accordingly. Next, the
incisions were then closed with mid columellar incision closed with
interrupted 6-0 Prolene sutures. The marginal incisions were closed
with interrupted 5-0 chromic sutures. The lateral columella portion
incisions were closed with interrupted 6-0 fast-absorbing gut
sutures.
Attention was then drawn toward the nasal base and reduction of the
patient's nostril flare. This was performed through modified Weir
excisions. A marking pen was used to mark crescent shaped incisions
along the nasal facial junction extending into the nasal alar base
with great care taken not to disrupt the natural boundary between
the nasal alar junction. Local anesthesia was then used to inject
these areas. A #11 blade was then used to excise a portion of the
nasal ala and extending into the nasal base. This allowed for an
advancement rotation flap essentially to reduce the nasal alar base.
3 mm of alar were removed bilaterally. The incisions were then
closed with combination of interrupted 5-0 PDS sutures followed by
vertical mattress sutures of 5-0 Prolene extranasally and intranasal
vertical mattress sutures using 5-0 plain gut sutures. The patient
was again checked for adequate symmetry and support prior to
completion. Telfa tacos coated in bacitracin ointment were placed
in the left and right nasal cavity to be removed by the patient on
postoperative day 1. This completed the procedure. The patient was
then turned back to Anesthesia, where he was awakened, successfully
extubated, and taken to the recovery room in stable condition. He
tolerated this procedure well without complications.
My original thinking was to just code 30420 for septorhinoplasty, but as this is stated to be revision surgery, should I be coding from 30410-30430 along with 20912 for the septal graft? Typically, I never code septal grafts separately, but I'm not sure here since it was obtained through a separate incision. Also, should I be coding for the mentioned nasal ala rotation flap? Any help would be appreciated. Thanks.
