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Wiki Repair Left Nasal Valve

MBA101

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Could someone please assist with this operative report? I don't know what cpt code to use. Here is the description of the procedure as dictated:

Preoperative Dx: Left nasal valve collapse with left anterior nasoseptal deviation.

Type of Procedure: Repair Left nasal valve with cartilage from revision septoplasty.

A 1X1 cm portion of anterior septal cartilage was removed, maintaining the flaps intact with an incision on the left side of the nasal septum. This allowed for better airflow, and this was closed with 4-0 chromic, and 4-0 plain was used as coapting.

A separate incision was then made on the inferior border of the left lower lateral cartilage, and a small pocket developed over that and carried out laterally. The cartilage was then trimmed and then placed in that pocket to aid in the valvular problem that was on the left side. There was good hemostasis.

Thank you for any assistance.

Standard nasal dressings wereput in place, and Surgicel was placed in the valvular area and one 4-0 chromic suture was used to close the infracartilaginous incision on the left.
 
I would code it the following way:

CPT 30465-52 Repair of Nasal Vestibular Stenosis
CPT 20912-51 Cartilage Graft; nasal septum

Note parenthetical instructions below in the CPT book, 30465 is a bilateral procedure, when done unilaterally, use mod. 52; also note that it does not include obtaining the graft so you can charge for that as well; this code does have a CCI Edit with regards to 30520 which is inclusive.

Jennifer
CT ENT
 
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