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Functional Rhinoplasty/Vestibular Stenosis Repair

Sherry Posted Tue 26th of July, 2011 17:33:49 PM

Elevation of mucoperichondrial flaps and mucoperiosteal flaps off the floor was done with Cottle elevator. The septal cartilage was cut through and elevation of mucoperichondrial flaps off the septum and mucoperiosteal flaps off the floor were carried out anterior to posterior. The cartilage was cut superiorly keeping a 2 cm intact rim strip. This was attached posteriorly with Freer elevator from perpendicular plate of the ethmoid and vomer and delivered with platform forceps frontal grafting. dissection was carried posteriorly and allowed Takahashi forceps to remove the deflection of these bony plates and 4mm chisels were used to remove the large spur off the maxillary crest. This markedly opened the nasal airway. These septal leaves were coapted w/ 4-0 plan gut suture sewn back and forth in mattress fashion w/SC1 needle. At this time, the nose was inspected and thought to have complete collapse in the mid vault area primarily cartilaginous. There was very little support of the tip which was quite narrow, and therefore, had convex lateral segments. This contributed to the inward movement on inspiration. An open technique was carried out. Rim incisions were connected through an inverted V and mid columellar. Elevation was done with curved sharp scissors. Care was taken to avoid injury of the lower lateral cartilages. These were thought to be quite wide but convexed in the lateral component offering very narrow domal segments. The saddling was immediately evident in the mid vault. Dissection was carried up onto the nasal bridge. At this time, the cartilage was trimmed on the back table to create two segments measuring 6mm x 2.5cm; it was stacked and 5-0 Monocryl was used to sew these together. Abolster of the foil packet was used with a 5-0 Monocryl through the foil pack but through the superior aspect of the midline with elevated dorsum down through the graft returning through the graft and coming up through the skin and back through the foil packet. This then allowed this to be teased into position. It was sewn down. The graft was placed underneath the elevated cephalic margins of the lower lateral cartilages and sewn in with 5-0 Monocryl on each side. A columellar strut measuring 4mm x 18mm was placed in a pocket created within the medial crura of the lower lateral cartilages. This was stabilzed with suture. The domes were then medialized to prevent bosse formation with suture. Nasal dressing applied.

SuperCoder Answered Wed 27th of July, 2011 09:41:56 AM

Documentation MUST for functional rhinoplasty:
-State why the procedure was medically necessary
-Clearly reflect the medical problem(s) in the patient's history
-Address the patency of the nasal passages
-State the degree of obstruction

If there is medical necessity for both rhinoplasty and septoplasty procedures, then you can bill combination cpt code 30420.
***

If the surgeon performs septoplasty as there is medical necessity, but rhinoplasty is performed as a cosmetic procedure (where the patient is self-paying for the rhinoplasty procedure), code the appropriate rhinoplasty code(30400/30410 as appropriate) for the cash portion billing to the patient, and submit CPT code 30520 (septoplasty) to the insurance company.
***

Additionally, for repair of vestibular stenosis, use code 30465

****
Finally, consider the CCI edits issue with the combination of codes those you are going to use.

Sherry Posted Wed 27th of July, 2011 18:34:11 PM

Thank you so much for your detail explanation. It is good to have conformation from another coder. The surgery was Functional Rhinoplasty with VSR.

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