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Chapter Postoperative Management of the Rhinoplasty Patient 145
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It is particularly important to recognize patients’ concerns and anxiety in the
early postoperative period. Many patients requesting rhinoplasty have expectations of how they will look aer their surgery, but because of swelling and bruising, it may be several weeks aer surgery before patients can really begin to appreciate the changes to their appearance. It is essential to provide support during
this interval and reassure patients that what they are seeing is a normal part of
the recovery process.
It may take some time before patients can really begin to appreciate the changes
following rhinoplasty. During this time, patients require support and reassurance
that what they are seeing is a normal part of the recovery process.
KEY POINTS
■
Patients should receive detailed postoperative instructions before surgery. Review of these instructions prepares patients for what is to be expected, claries and reinforces the details of the procedure, minimizes anxiety, and helps
involve patients in their own care.
■
Patients must be instructed to keep the head elevated and to apply cold compresses to the eyes and cheeks frequently for the rst hours aer surgery.
ese measures are useful for decreasing postoperative swelling, which is normal and may not reach its peak until to hours aer surgery.
■
Patients should be informed of activity restrictions as these restrictions will
oen inuence when they return to their normal daily activities and also when
they return to their work.
■
Nasal packing is generally unnecessary and is uncomfortable for the patient.
Doyle septal splints are frequently used aer septal reconstruction and/or turbinate surgery because they stabilize septal structures in the midline, protect
the mucosa and prevent synechiae.
■
Internal nasal splints should be placed using a speculum under direct visualization to avoid damage and possible perforation of the mucoperichondrium.
■
It is important to remove the internal splints before removing the external
splint to prevent potential displacement of the osteotomies and/or rupture of
sutures as the splints are extracted.
■
Nasal packing is generally unnecessary and is uncomfortable for the patient.
Doyle septal splints are frequently used aer septal reconstruction and/or turbinate surgery because they stabilize septal structures in the midline, protect
the mucosa and prevent synechiae.
■
Overcompression of the nasal structures with the splint should be avoided,
because this can lead to medial displacement of the osteotomized segments
of bone.
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■
Minimal postoperative pain medication is normally required aer rhinoplasty.
Antibiotic agents and steroids are routinely used preoperatively.
■
In general, postoperative bleeding will be mild and can be controlled by elevating the head to degrees and gentle nostril pressure for minutes. is
should be followed by spraying each nostril with oxymetazoline. If these measures fail, the patient should be seen. Cauterization with silver nitrate, anterior/
posterior nasal packing, operative exploration and cauterization, and angiographic embolization (rare) may be required.
■
Purulent collections require drainage and irrigation.
■
Taping to control so tissue edema is particularly useful in the rst week or
two aer removal of the dorsal splint.
■
Steroid injections may be required to treat persistent edema and should be deep
in a plane just supercial to the perichondrium. Subdermal steroid injections
should be avoided, because they can lead to hypopigmentation, tissue atrophy,
and ulceration.
■
Signicant early postoperative irregularities should be corrected immediately
because they will not improve. is early intervention will help to prevent unnecessary patient distress and dissatisfaction.
■
It may take some time before patients can really begin to appreciate the changes
following rhinoplasty. During this time, patients require support and reassurance that what they are seeing is a normal part of the recovery process.
REFERENCES
1. Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg :e-e, .
2. Rohrich RJ. Rhinoplasty planning. Presented at the Twelh Dallas Rhinoplasty Symposium, .
3. Rohrich RJ, Byrd HS, Oneal RM, et al. Management of the rhinoplasty patient. Perspect Plast Surg
:, .
4. Gorney M, Martello J. Patient selection criteria. Clin Plast Surg :-, .
5. Rohrich RJ. Streamlining cosmetic surgery patient selection—just say no! Plast Reconstr Surg
:-, .
6. Goin MK, Rees TD. A prospective study of patients’ psychological reactions to rhinoplasty. Ann
Plast Surg :-, .
7. Broughton G II, Crosby MA, Coleman J, Rohrich RJ. Use of herbal supplements and vitamins in
plastic surgery: a practical review. Plast Reconstr Surg :e-e, .
8. Cochran CS, Landecker A. Prevention and management of rhinoplasty complications. Plast Re-
constr Surg :e-e, .
9. Goldwyn RM. Unexpected bleeding aer elective nasal surgery. Ann Plast Surg :-, .
10. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr Surg :-;
discussion -, .
11. Hanasono MM, Kridel RW, Pastorek NJ, et al. Correction of the so tissue pollybeak using triam-
cinolone injection. Arch Facial Plast Surg :-; discussion , .
12. Gruber RP. Early surgical intervention aer rhinoplasty. Aesthet Surg J :-, .
13. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr
Surg :-, .
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9
Coding of Reconstructive
and Cosmetic Rhinoplasty
Procedures
Raymond V. Janevicius
A
lthough CPT coding for nasal procedures is relatively straightforward, confusion may arise on various fronts. Some inconsistencies are present in the CPT
book, and precisely what constitutes a global code for rhinoplasty procedures is
sometimes unclear. Overlap between reconstructive and cosmetic rhinoplasty often occurs, and distinguishing between cosmetic and reconstructive procedures
is critical from a coding standpoint.
GENERAL CONSIDERATIONS
From a coding perspective, no distinction is made between open rhinoplasty
procedures and endonasal procedures. ese are considered “approaches,” and
the CPT book does not dierentiate between the two. Codes are selected based
on the procedures performed on the cartilage and bone. An incision in the columella is not separately reported, nor is the closure of this incision.
PRIMARY PROCEDURES
A tip rhinoplasty, whether for posttraumatic deformity or for purely cosmetic
reasons, is coded if no other nasal procedure is performed (that is, no osteotomies or septal surgery).
ponents of a tip procedure, including cephalic trim and other cartilage excisions,
cartilage suturing, cartilage repositioning, graing, and scoring techniques. Code
includes surgery on both alar cartilages, because it reads “nasal tip.” Surgery on each alar cartilage should not be coded separately, nor should the bilateral modier be appended to this code.
,
Code is global and encompasses all com-
147
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Commonly Used CPT Codes for Nasal Surgery
30400
30410
30420
30430
30435
30450
30460
30462
30465
30520
20912
21210
21230
21235
15760
Rhinoplasty, primary; lateral and alar cartilages and/or tip
Rhinoplasty, primary; bony pyramid, lateral and alar cartilages and/or tip
Rhinoplasty, primary; bony pyramid, lateral and alar cartilages and/or tip, including major septal repair
Rhinoplasty, secondary; minor revision (nasal tip)
Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
Rhinoplasty, secondary; major revision (nasal tip and osteotomies)
Cle lip rhinoplasty, including columellar lengthening; tip only
Cle lip rhinoplasty, including columellar lengthening; tip, septum, osteotomies
Repair of nasal vestibular stenosis (for example, spreader graing, lateral nasal wall
reconstruction)
Septoplasty or submucous resection with or without cartilage scoring, contouring,
or replacement with gra
Septal cartilage gra (septal donor site)
Bone gra to nose (includes obtaining gra)
Rib cartilage gra to nose
Ear cartilage gra to nose
Composite gra
Placement and positioning of a cartilage gra are included in code , but
harvest of the gra is separately reported. Septal cartilage harvested for a tip gra
is reported with code ; costal cartilage harvest is reported with code .
us, a tip rhinoplasty with placement of a septal cartilage gra is coded:
30400
20912-
Tip rhinoplasty
Harvest of septal cartilage
If surgery is performed on the bony pyramid in addition to the tip rhinoplasty,
code is used alone. is code includes surgery on the tip as well as bony
work. e tip work is not coded separately, because this is included in the global
code ; that is, is not reported in addition to code . us a rhinoplasty that includes a cephalic trim, dorsal reduction, and osteotomies is coded
.
Harvest of bone or cartilage gras is reported separately. A rhinoplasty including
surgery on the tip with a cranial bone gra to the dorsum is reported as:
30410 Rhinoplasty, tip and bony dorsum
21210- Bone gra
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A septorhinoplasty is coded . is code includes septoplasty/submucous
resection, bony pyramid surgery, and tip surgery. Code is global and includes codes , , and , which should not be reported in addition
to code . is would be unbundling.
Code includes harvest and placement of septal cartilage gras but does not
include harvest of bone gras or nonseptal cartilage gras. us a septorhinoplasty requiring dorsal augmentation with septal cartilage is reported with code
alone, whereas a septorhinoplasty requiring dorsal augmentation with rib
cartilage is reported as:
30420
21230-
Septorhinoplasty
Rib cartilage
When a septoplasty or submucous resection is performed alone (not in conjunction with tip or bony dorsum surgery), code should be used. is code is
global and includes all components of septal surgery (resection, scoring, and suturing). If septal surgery is performed at the same time as a primary rhinoplasty,
however, use the global septorhinoplasty code: . Because code includes septoplasty, is not reported in addition to .
SECONDARY PROCEDURES
Secondary rhinoplasty codes are also global. A “minor” revision (nasal tip) is
coded and includes surgery on the tip cartilages.
vision (bony work with osteotomies) is coded and includes surgery on the
bony dorsum, but not the tip. When a “major” revision (tip and osteotomies) is
performed, use code . is includes tip cartilage and bony dorsal surgery.
None of the secondary rhinoplasty codes (, , or ) includes septal surgery. If septal surgery is performed during these secondary procedures, it
is coded separately (-). For example, a secondary rhinoplasty involving
surgery on the bony dorsum as well as a septoplasty is coded:
30435
30520-
Secondary rhinoplasty, bone only
Septoplasty
Note that this is a dierent convention from that for primary rhinoplasty, where
the primary septorhinoplasty code, , includes septal surgery. No single
global code describes secondary septorhinoplasty: two codes are required to report the procedure. is inconsistency in the CPT book need not be a source of
confusion if the surgeon understands what is included in each global code.
,
An “intermediate” re-
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No single global code describes secondary septorhinoplasty: two codes are required to report the procedure.
None of the secondary rhinoplasty codes includes harvest of cartilage or bone
gras. ese procedures are reported in addition to the secondary rhinoplasty
codes. Consider a secondary septorhinoplasty, including tip and bone work,
which requires a conchal cartilage gra for tip reconstruction. ese procedures
are coded:
30450
21235-
30520-
Secondary rhinoplasty, tip and bone
Conchal cartilage gra
Septoplasty
is is not unbundling, since each procedure is itemized using CPT guidelines.
e code does not include obtaining the cartilage gra or septal surgery,
so these two procedures are reported separately.
CLEFT LIP RHINOPLASTY
Two new codes were created in to address the intricacies of cle lip rhinoplasty procedures. Rhinoplasty procedures on patients with cle lip nasal deformities are not reported with codes -.
A tip rhinoplasty for a cle lip nasal deformity is reported as . is code
is similar to the primary tip rhinoplasty code in that it does not include
osteotomies or septal surgery. Code includes all components of a tip procedure, including cartilage excision, cartilage suturing, cartilage rotation and repositioning, graing, and scoring techniques. It is global and comprises surgery
on both alar cartilages; using separate codes for each alar cartilage is unbundling.
e code describes rhinoplasty for cle lip nasal deformity that includes
surgery on the tip as well as the nasal bones and the septum. us is global
and includes everything described by code , plus surgery on the septum
and nasal bones, including osteotomies.
Both and include columellar lengthening, regardless of technique.
So tissue advancement techniques to lengthen the columella, including aps,
are not separately reported, because they are included in each of these global
codes: and . To code separately for a ap () used for columellar lengthening is unbundling.
,,
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If cartilage or bone gras are used, their placement is included in the global codes
and . Harvest of these gras is reported separately, however, unless
a septal cartilage gra is harvested during the septal surgery described in code
. Because septal surgery is performed, the harvest of a septal gra within
the same operative eld is included in the global code .
VESTIBULAR STENOSIS
In a code was introduced to describe procedures for vestibular stenosis and
vestibular collapse.
tilaginous surgery necessary to correct vestibular stenosis, including spreader
gras, composite gras, and lateral nasal wall reconstruction. e harvest of
gras, however, is separately reported. Code is an unusual CPT code, because it describes a bilateral procedure; to report a unilateral vestibular reconstruction, append the “reduced services” modier -: -.
If we consider a patient with bilateral alar collapse and narrowing of the nasal
valves, bilateral septal spreader gras are placed, as well as bilateral conchal cartilage gras for alar support. is procedure is reported as:
30465
Repair nasal vestibular stenosis, bilateral
21235-
20912-
,
Code is global and describes the so tissue and car-
Conchal cartilage gras
Septal cartilage spreader gras
If a septoplasty is performed in addition to the above procedures, it is separately
reported (). e harvest of septal cartilage for spreader gras, however, is
not reported separately, as the gras are harvested from within the same operative eld (septoplasty). us:
30465
21235-
30520-
Repair nasal vestibular stenosis, bilateral
Conchal cartilage gras
Septoplasty
TISSUE GRAFTING
All rhinoplasty codes (primary, secondary, and cle lip rhinoplasty) include the
placement of bone and cartilage gras. Harvesting the gras, however, is separately reported, and the appropriate gra harvest codes (, , ,
, and ) are used in addition to the rhinoplasty codes.
All rhinoplasty codes (primary, secondary, and cle lip rhinoplasty) include the
placement of bone and cartilage gras.
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Two important exceptions should be noted. If the septum is operated on for any
reason (, septorhinoplasty; , cle lip septorhinoplasty; , septoplasty), then the harvest of gras from the septum to be placed elsewhere is not
separately reportable, since the gras are harvested from within the same operative eld. Code is not used to report septal gra harvest in such situations.
If the tissue gra is the only surgical procedure performed to correct the nasal deformity, then only the tissue gra procedure is reported and the rhinoplasty code
is not used. e tissue gra codes include harvest and placement of these gras
in these situations. A rib cartilage onlay gra for dorsal augmentation where no
other nasal surgery is performed would be reported with code alone.
COSMETIC VERSUS RECONSTRUCTIVE PROCEDURES
Rhinoplasty CPT codes do not distinguish between cosmetic and reconstructive procedures.
dorsal hump with osteotomies. is code also describes a dorsal straightening
aer trauma that requires osteotomies. It is ICD- codes that indicate the reasons
procedures are performed. For a purely cosmetic procedure use code V.. For
a posttraumatic procedure use ICD- codes . (acquired nasal deformity),
. (malunion of nasal fracture), or . (late eect of nasal fracture). Cosmetic procedures are not submitted for insurance reimbursement, whereas reconstructive procedures are oen insurance reimbursable.
,
Code , for example, describes cosmetic reduction of a
Rhinoplasty CPT codes do not distinguish between cosmetic and reconstructive
procedures.
For a procedure that is part cosmetic and part reconstructive, however, which
procedure is done and for what reason should be itemized—this is not unbundling. e reasons for each procedure are indicated with appropriate ICD-
codes. For example, a septoplasty is performed for breathing obstruction resulting from a posttraumatic nasal septal deviation. e patient requests that the
surgeon narrow her nasal tip “while you are there.” Because a portion of this
procedure is cosmetic, the procedures are coded as follows:
30520 Septoplasty ICD- codes: , ., .
30400- Tip rhinoplasty ICD- code: V.
e septoplasty should be preauthorized in writing with the insurance company
preoperatively. Only one operative report is dictated, describing both procedures.
e operative report must clearly distinguish which parts of the procedure are
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cosmetic and which are reconstructive, including operating times for each portion. e cosmetic portion of the procedure should not be submitted for thirdparty reimbursement.
OTHER CODES
e nasal fracture codes (-) are not used for septorhinoplasty procedures, although one may be treating the sequelae of trauma. e nasal fracture
codes are used to describe reductions of acute fractures. When osteotomies or
septal surgeries are performed on healed fractures, septorhinoplasty codes are
used.
e nasal fracture codes are not used for septorhinoplasty procedures, although
one may be treating the sequelae of trauma.
CPT should not be used for septorhinoplasty procedures. is code describes “septal or other intranasal dermoplasty,” a procedure for telangiectatic
nasal bleeding, in which the septal mucosa is removed and replaced with a skin
gra. Unfortunately, the text for this code used to read “reconstruction, functional, internal nose” and has caused some confusion because of the use of the
term “reconstruction.” Procedures performed for septal deviation should be
coded or .
CODING EXAMPLE
A patient on whom a cosmetic rhinoplasty was performed several years ago is
involved in an accident and fractures his nose. He is seen several weeks later, after he develops breathing diculty. Examination reveals that the nasal dorsum
is collapsed and deviated to the le. e septum is deviated into the le nasal
cavity, and air entry is diminished on the le side. A septorhinoplasty, including a dorsal rib cartilage gra, is performed to correct the deformity and relieve
breathing diculty. No tip work is necessary.
Diagnoses
738. Acquired nasal deformity ()
905. Late eect of fracture of nasal bones ()
470 Deviated nasal septum ()
478. Airway obstruction ()
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Procedures
30435 Rhinoplasty, secondary; (osteotomies) (, )
30520-
21230-
Septoplasty (, )
Rib cartilage gra (, )
A previous rhinoplasty had been performed, so the secondary rhinoplasty code,
, is used. Because none of the secondary rhinoplasty codes includes septal
surgery, the septoplasty is coded separately. e harvest of the rib cartilage gra
is also reported separately.
CONCLUSION
Coding rhinoplasty procedures is generally straightforward. Reporting more
complex procedures, however, including those requiring graing, requires a detailed knowledge of CPT codes available and what each code includes in its global
description.
RHINOPLASTY CODING PEARLS
■
Placement of tissue gras is included in all rhinoplasty codes.
■
Harvest of tissue gras is separately reported, unless the gra is harvested from
within the operative eld.
■
Specically, rhinoplasty codes , , , , , ,
include placement of tissue gras as part of the procedures. Harvesting of the
gras is reported with codes , , , and in addition to the
primary rhinoplasty code.
■
Rhinoplasty codes (septorhinoplasty), (cle lip rhinoplasty, including septum), and (septoplasty) involve surgery on the septum. If a
septal cartilage gra is harvested and used elsewhere in the nose, the harvest
of the gra is included, so is not separately reported.
■
If a nonseptal gra is used for procedures reported with codes (septo
rhinoplasty), (cle lip rhinoplasty, including septum), and (septoplasty), the gra harvest is reported separately (, , ).
■
Secondary rhinoplasty procedures do not include septal surgery, which is reported separately ().
■
All nasal procedures which will be submitted for insurance reimbursement
must be preauthorized in writing by the payer before surgery.
■
When a combined reconstructive and cosmetic rhinoplasty is performed, only
one operative report is dictated.
-
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