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Coding Respiratory System Procedures

Vol. 16 •Issue 8 • Page 16
Coding Corner

Coding Respiratory System Procedures

Preoperative Diagnosis: Obstructive sleep apnea (OSA) with nasal airway obstruction.

Postoperative Diagnosis: OSA with nasal airway obstruction.

Procedures Performed: Uvulopatatopharyngoplasty, with septoplasty and submucosal resection; YAG laser endoscopic partial resection of the inferior turbinates, bilateral.

Anesthesia: General.

Operative Technique: The patient was placed in the supine position. Under general endotracheal anesthesia, the patient's nose was injected with 1% Xylocaine, Marcaine and adrenalin, cocainized with 10% cocaine and adrenalin. The patient's nose showed an S-shaped deformity of the septum with anterior obstruction and posterior obstruction as well. The patient's previous rhinoplasty did not include the septum as it was intact.

A left hemitransfixion incision was made, and the left mucoperichondral flap was elevated. The primary problem was an anterior deflection of the septum. Posteriorly, a perpendicular plate of the ethmoid deformity actually impinged on the left middle turbinate. Resection of this area and reconstruction of the septum allowed us to sew the flaps back into place with 4-0 plain suture.

A YAG laser was used to cut into the bone. A Rubin scissor was then used, followed by an upper lateral cartilage scissor to curve-cut the posterior aspect of the resection. This left the inferior and posterior portions of the turbinates intact. Gelfoam was placed. Septal splints were sewn into place. Packs were placed.

Attention was then turned to the throat where a Crowe-Davis mouth gag was put into place and attached to the Mayo stand. We then proceeded to use the YAG laser at 12 watts of continuous power to resect approximately 2 cm of soft palate. Irrigation was performed. No blood loss occurred.

The patient tolerated the procedure well and was taken to the recovery room in good condition.

ICD-9-CM Code Assignments

Preoperative ICD-9-CM Diagnosis: OSA, nasal airway obstruction.

327.23 Obstructive sleep apnea (adult) (pediatric)

478.1 Other diseases of nasal cavity and sinuses

Postoperative ICD-9-CM Diagnosis: OSA, nasal airway obstruction.

327.23 Obstructive sleep apnea (adult) (pediatric)

478.1 Other diseases of nasal cavity and sinuses

CPT Code Assignment, Rationale

A septoplasty was performed to reshape the nasal septum and to correct deformities that cause nasal obstruction. During the septoplasty, the physician made an incision in the septal mucosa and elevated the mucoperichondrium from septal cartilage. The deviated portion of the septum and excess cartilage were excised. Septal splints were sewn in place to support the septum during the healing process.

For the septoplasty, check that term in the index. The code listed is 30520, which should be assigned as the first code for the facility assignments.

30520 Septoplasty or submucous reseresection, with or without cartilage scoring, contouring or replacement with graft.

During the turbinectomy procedure, the physician removed the posterior portion of the inferior turbinates through a submucous incision. This procedure was done bilaterally. For the resection of the turbinates, look up Turbinate in the index. The first entry under this term is Excision 30130-30140. Go to the Respiratory System/Surgery section of the manual and read the descriptions for each of these codes. You will see that code 30140 is the correct choice and should be assigned for both the facility and professional components.

30140 Submucous resection inferior tur-binate, partial or complete, any method.

Because this procedure was performed bilaterally, be sure to report modifier -50 (bilateral procedure) with this code for both the facility and professional components. For the professional component you will also need to report modifier Ð51 to identify that it is a multiple procedure.

During the uvulopatatopharyngoplasty, the physician removed excess tissue from the uvulva, soft palate and pharynx. Incisions were made in the soft palate mucosa, and this area and part of the uvula are partially excised. The uvula is sutured first and then the remaining mucosa is closed, which increases the size of the oropharynx.

Although the physician indicated in the "Procedures Performed" section of this operative report that an uvulopatatopharyngoplasty was performed, documentation does not support this procedure. Documentation must be included in the body of the operative report to verify performance of this procedure. The coder must query the physician as to the exact procedure performed.

If a uvulopatatopharyngoplasty was not performed, you will assign code 42120 (resection of palate or extensive resection of lesion).

If the uvulopatatopharyngoplasty was performed, you would check the index under the term Uvula and then look for the term Excision 42140-42145. After reading all of the descriptions in the text portion of the manual, you will see that the next assignment is the following code:

42145 Palatopharyngoplasty (e.g., uvulopalatopharyngoplasy, uvulopharyngoplasty)

If just the resection of the palate was performed, reference the term Resection in the index and under it check the term Palate. The description of this code will lead you to the description of code 42120 (resection of palate or extensive resection of lesion).

Summary of Code Assignments

Facility Component

A modifier -50 must be assigned to the third code to indicate the bilateral procedure performed.

30520 Septoplasty or submucous reseresection, with or without cartilage scoring, contouring or replacement with graft

42145* Palatopharyngoplasty (e.g., uvulopatatopharyngoplasty, uvulopharyngoplasty)

30140-50 Submucous resection inferior turbinate, partial or complete, any method

Professional Component

Like the facility component, you must assign modifier -50 to code 30140 to indicate the bilateral procedure. In addition, you will need to assign modifier -51 to the second and third codes of the professional component to indicate that they were multiple procedures.

42145* Palatopharyngoplasty (e.g., uvulopatatopharyngoplasty, uvulopharyngoplasty)

30520-51 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft

30140-50-51 Submucous resection inferior turbinate, partial or complete, any method n

Kathleen E. Mundy is senior healthcare consultant for Medical Learning Inc. (MedLearn®), St. Paul, MN.

* Coders must query the physician regarding this procedure.




     

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