Camille Posted Wed 27th of November, 2019 12:15:53 PM
Indication: Deviated nasal septum. Procedure note excerpt: "Starting on the left-hand side, using an Acclarent 16-mm airway balloon, it is placed along the nasal floor under endoscopic guidance. It is dilated to 8 atmospheres of pressure and held for 2 minutes. A second dilation is performed more caudally as well on the left-hand side. Continuing, on the right-hand side, similar process. Continuing, this did nicely mobilize the caudal septum." Question: this is a type of septoplasty, but does not include the actual work and only a fraction of the time described in CPT 30520 (Septoplasty). There isn't a balloon dilation CPT specifically for the nasal septum. Should I code this to CPT 30999 Unlisted Procedure Nose? Thank you kindly!
SuperCoder Answered Mon 18th of November, 2019 02:29:38 AM
Thanks for your question.
Physician has performed dilation of the nasal cavity to repair the deviated septum. The deviated septum was repaired via balloon dilation, but we do not have a CPT code for this type of septoplasty. Hence unlisted code should be reported.
Please feel free to write if you have any question.
Camille Posted Mon 18th of November, 2019 12:26:21 PM
Thank you for confirming that. Will you please advise me on this related question? The balloon procedure was performed (as per my Procedure note excerpt above); but surgeon determined the balloon procedure failed to create the desired mucosal defect on the left and so had to make a "small left hemitransfixion incision, working through this and with a combination of headlight and endoscope, freed the caudal cartilage off the nasal spine. While preserving the first 1.5 cm and 1.5 cm on the dorsal strut, went ahead and took this out until reaching the bone. This made a significant improvement in the left nasal airway. Hemitransfixion incision was closed using 4-0 chromic in a quilting suture..." The procedure was a combination balloon dilation and partial incisional septoplasty. Do you advise I still code with an unlisted code as the full balloon procedure was performed? Thank you very much!
SuperCoder Answered Tue 19th of November, 2019 02:17:15 AM
This procedure now should be considered as septoplasty and you should report septoplasty. Balloon procedure cannot be reported since the desired result was achieved from the final procedure, which was septoplasty.
Hope this helps.
In a different scenario the surgeon performs the balloon procedure bilaterally (as described in first paragraph above) and then..."This created a septal fracture and improved nasal airway. A posteriorly based hemitransection incision was made under direct vision on the right side medially onto the fragments created. These bony and cartilaginous fragments were then removed. A quilting suture of 4-0 chromic was applied..." How much or what work must be done after the balloon procedure in order for me to code Septoplasty (30520) instead of the balloon procedure? Thank you!
SuperCoder Answered Thu 28th of November, 2019 03:28:21 AM
Thanks for your question.
Since the reason of the procedure was to straighten the deviated septum and the final result was achieved via the hemitransection incision, removing bony and cartilaginous fragments, and then the closing the wound with sutures. This all fulfils the medical necessity to bill septoplasty. Hence you may report code 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft). In this procedure, provider may remove cartilage and may elevate mucosal flap also.
You cannot report balloon procedure separately because the physician used ballon as a device to repair for deviated septum. Hence only septoplasty would be reported in this case.
Hope this helps. If you need more assistance, please let us know with a clear query.
Camille Posted Mon 02nd of December, 2019 20:00:24 PM
Thank you very much!
SuperCoder Answered Tue 03rd of December, 2019 00:57:02 AM
Thank you, happy to help.