My initial hunch was 30520; however, I was able to locate this article.
Sometimes the otolaryngologist has to repair damage from a nasal fracture that occurred a long time ago because the patient has a deviated septum – among other things – that is causing breathing problems. But unless the otolaryngologist includes other diagnoses (other than just a deviated septum) that show that the repair was medically necessary, some payers may not reimburse the procedure.
Many payers consider the repair of a deviated septum as a cosmetic procedure unless you can show that the patient’s health is affected. To indicate that the repair procedure was medically necessary, you need to include another diagnosis, or a sign or symptom, supported by the physician’s notes
Example: The otolaryngologist treats a female patient with a deviated septum and ethmoidal sinusitis that is not responding to antibiotic treatment. He learns that when the patient was a youngster, she broke her nose playing baseball. At the time the nasal fracture was repaired by closed treatment with stabilization (21320); prior to the incident, the patient had no breathing or sinus problems. The otolaryngologist decides to perform a septoplasty (30520) and a partial ethmoidectomy (31254) to repair the deviated septum and treat the sinusitis.
To get paid for the septoplasty, the otolaryngologist has to document the nasal obstruction that informed his decision to perform the septoplasty. If the otolaryngologist notes that the septoplasty was performed first to provide easy access to the sinus, you’re sunk. Instead, inform the otolaryngologist to include the medical reason the septoplasty was performed ( it may not be enough to simply note that there was a nasal obstruction.)The otolaryngologist should note the percentage of obstruction in each nostril; for example, ‘the patient has an S-curvature septum that causes a 70% obstruction on the right and an 80% obstruction on the left. During rhinitis and allergy season, there is total obstruction.
As for the claim itself, it is recommended that you list the diagnosis that provides medical necessity for the procedure first. In some geographic locations, the deviated septum alone provides medical necessity, but elsewhere, you need to list the nasal obstruction first, because that’s why the patient with the deviated septum saw the otolaryngologist in the first place. In the case described above, she’d use 478.1 (other diseases of nasal cavity and sinuses) as the primary diagnosis and 470 (deviated nasal septum) secondarily. For the ethmoidectomy, the correct diagnosis code is 473.2 (ethmoidal sinusitis). Although the examples of 478.1 listed in the ICD-9 manual are unrelated to nasal obstruction, the Index to Diseases in the Manual points to 478.1 for this condition.
Note: Although many payers bundle septoplasties with endoscopic sinus surgery, this is inappropriate because the two procedures are performed for separate conditions, according to the AmericanAcademy of Otolaryngology – Head and Neck Surgery, which states: “Most commonly, the septal deformity is blocking the nasal airway and obstructing the patient’s breathing. This is independent of the sinus pathology and performing the sinus operation alone would be insufficient to correct the pathology.”
In some cases, the late repair of a nasal fracture involves more than repairing a deviated septum.Sometimes the otolaryngologist also has to refracture the nasal bone as well as repair the septum, which you report using 21335 (open treatment of nasal fracture; with concomitant open treatment of fractured septum).In such cases you should also include ICD-9 code 802.0 (fracture of nasal bones, closed). This lets the insurer know why you had to do more than a septoplasty, noting that some payers may also want to see 905.0 (late effect of fracture of skull or face bone) before being convinced that the nasal refracture was medically necessary.
If the patient also has a severe nasal deformity, the otolaryngologist may decide that functional rhinoplasty with septal repair (30420) is necessary. Because payers immediately associate rhinoplasty with cosmetic procedures, the claim likely will be denied on first submission, even if the diagnosis codes indicate medical necessity, and you’ll have to submit the claim with supporting documentation before payment becomes even a possibility.
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