AnneCline
Networker
Any help with cpt coding for this op is greatly appreciated. Wasn't sure if 30465 should be used.
----- is a 39-year-old male seen in consultation for nasal
breathing problems. ----- has had previous nasal surgery. He still
reports difficulty breathing through the left side of his nose. On
physical examination, he has redundant left septal mucosal tissue creating
a medial obstruction of the internal nasal valve. I recommended repair
with a nasal septal flap to open up the left nasal airway. The risks,
complications, alternatives, and benefits were reviewed. Informed consent
was obtained.
REPORT: ----- was brought to the operating room and placed supine. The
department of anesthesia administered general anesthetic via LMA. The face
was then prepped and draped in the usual fashion. One percent lidocaine
with 1:100,000 epinephrine was infiltrated locally. Afrin nasal spray was
applied topically. Redundant left septal mucosal tissue was noted at the
mucocutaneous junction. An elliptical incision was created at the junction
and the redundant mucocutaneous tissue was excised down to the
perichondrium. The left septal mucosa was then elevated posteriorly and
advanced. The defect was reapproximated with 5-0 plain gut in simple
interrupted fashion. This opened up the intranasal valve medially.
Bleeding was self limiting. Additionally, a right marginal rim stab
incision was created and subcutaneous dissection was performed of the right
upper lateral cartilage in the area of the previous abscess and cellulitis
to break up any loculations and to allow for subcutaneous irrigation with
lidocaine with epinephrine. Bimanual palpation was then performed along
the right nasal ala. Bleeding was self limiting.
----- is a 39-year-old male seen in consultation for nasal
breathing problems. ----- has had previous nasal surgery. He still
reports difficulty breathing through the left side of his nose. On
physical examination, he has redundant left septal mucosal tissue creating
a medial obstruction of the internal nasal valve. I recommended repair
with a nasal septal flap to open up the left nasal airway. The risks,
complications, alternatives, and benefits were reviewed. Informed consent
was obtained.
REPORT: ----- was brought to the operating room and placed supine. The
department of anesthesia administered general anesthetic via LMA. The face
was then prepped and draped in the usual fashion. One percent lidocaine
with 1:100,000 epinephrine was infiltrated locally. Afrin nasal spray was
applied topically. Redundant left septal mucosal tissue was noted at the
mucocutaneous junction. An elliptical incision was created at the junction
and the redundant mucocutaneous tissue was excised down to the
perichondrium. The left septal mucosa was then elevated posteriorly and
advanced. The defect was reapproximated with 5-0 plain gut in simple
interrupted fashion. This opened up the intranasal valve medially.
Bleeding was self limiting. Additionally, a right marginal rim stab
incision was created and subcutaneous dissection was performed of the right
upper lateral cartilage in the area of the previous abscess and cellulitis
to break up any loculations and to allow for subcutaneous irrigation with
lidocaine with epinephrine. Bimanual palpation was then performed along
the right nasal ala. Bleeding was self limiting.