Otolaryngology Coding Alert

Nasal repair procedures such as rhinoplasties are among the most difficult services to obtain payment for because they are usually performed for cosmetic reasons. Related procedures, such as septoplasties and the repair of nasal vestibular stenosis (for which a new CPT code was created in 2001), may also be denied as cosmetic.

To obtain payment for these procedures when they are medically necessary, otolaryngologists should:

Use diagnosis codes that indicate the medical necessity of the procedure;

Provide clear and accurate documentation that supports the diagnosis codes and explains why the procedure was necessary; and

Appeal inappropriate denials.

Demonstrate Medical Necessity

Of the two types of rhinoplasties listed in CPT (primary and secondary), primary procedures are more likely to be performed for functional reasons (for example, an otolaryngologist may perform a functional rhinoplasty that includes septal repair on an adult with breathing difficulties whose nose was broken 17 years earlier). The manual includes three primary rhinoplasty codes:

30400 rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip; 19.78 relative value units (RVUs)

30410 rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip; 25.76 RVUs

30420 ... including major septal repair; 30.97 RVUs

Obtaining reimbursement for any of these procedures can be difficult because many carriers reject them as cosmetic without looking at the diagnosis or accompanying documentation, says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a coding and reimbursement firm in Lakewood, N.J.

Other payers may try to determine functional versus cosmetic percentage of the procedure and pay accordingly. This is absurd, Cobuzzi says, because you cant do one part of the procedure without the other.

Functional and cosmetic rhinoplasties can differ greatly. The ultimate purpose of the functional procedure (to improve airflow) often involves adding tissue, whereas the purpose of its cosmetic counterpart is usually to reduce the size of the patients nose by removing cartilage.

For example, when rhinoplasty corresponding either to 30400 or 30410 is performed to treat restricted airflow in the nasal passages, cartilage or bone grafts often are required to buttress the structure of the nose. In addition, such grafts may require significant additional work compared to cosmetic primary rhinoplasty.

Note: Placement of the graft is included in the rhinoplasty procedure, but obtaining the graft is separately payable and should be billed using the appropriate graft code. For bone grafts, use 20900 (bone graft, any donor area; minor or small [e.g., dowel or button]). For cartilage grafts, 20910 (cartilage graft; costochondral) or 20912 ( nasal septum) should be used, depending on where the graft was harvested. If, however, a graft is obtained from the septum and used to repair that structure, it [...]