Wiki 30802 cautery/ablation, mucosa, intramural

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coderguy1939

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Can anyone explain to me what to look for in an op report to determine if the this procedure was done intramural versus superficial? Thanks.
 
Looking at my medical dictionary it states "intramural" is within the substance of the wall or cavity or hollow organ and "superficial" says pertaining to or situated near the surface.

Hope this helps in your code selection.

Susan
 
Thanks for your response. The problem I'm encountering in the op report is that the doctor indicates the settings and number of lesions but not the depth of the lesioning. The procedure performed states submucous "resection" of inferior turbinates, but the procedure in detail states inferior turbinate "reduction" by RF diathermy. Do the RF settings and number of lesions help determine if this is 30802 or 30140?
 
Hello, I would sure like to help, perhaps you can give me a little more info, such as the actual dictated part of the operative note, also, what are the circumstances, are you billing for just the turbs or was this part of a nasal/sinus surgery?

Jennifer
ENT in CT
 
Here is the op report up through the turbinate reduction:

Postoperative DX:
Nasal obstruction w/nasal fracture
Nasal valve collapse
Turbinate Hypertrophy

Procedure:
Open reduction & internal fixation of nasal septal fracture
Nasal valve reconstruction w/septal cartilage graft
Submucous resection of turbinates w/RF diathermy

Indications:
The patient is a 19-year old male who has a markedly comminuted nasal fracture from trauma playing basketball with severe nasal obstruction, nasal valve deformity, collapse, and compensatory turbinate hypertropy, now for surgical correction.

After induction of general anesthesia, the table was turned and doughnut was placed on the head. The nose was topicalized with neo-synephrine pledgets and injected with 1%lidocaine with 1:100,000 epinehrine. After adequate time for vasoconstriction, the turbinates were reduced using radiofrequency low-temperature energy using the Somnus radiofrequency generator. Two treatments were delivered in each inferior turbinate for a total of 600 joules on fasterplasty mode, 85 degress target temperature.

The doctor then goes on to dictate the fracture repair.

Thanks for you assistance with this.
 
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