Question

What are the Service and ICD-10 Codes for this scenario?

LOCATION: Inpatient, Hospital

PATIENT: Art Schear

PHYSICIAN: Gregory Dawson, MD

PREOPERATIVE DIAGNOSES:

Obstructive sleep apnea

Nasal obstruction

Septal deviation

Bilateral inferior turbinate hypertrophy

Hypertrophic tonsils

POSTOPERATIVE DIAGNOSES:

Obstructive sleep apnea

Nasal obstruction

Septal deviation

Bilateral inferior turbinate hypertrophy

Hypertrophic tonsils

PROCEDURES PERFORMED:

1. Septoplasty

2. Bilateral inferior turbinate mucosal reduction with radiofrequency

3. Tonsillectomy

ANESTHESIA: General endotracheal anesthesia

INDICATION: The patient is a 16-year-old male with documented obstructive sleep apnea. He also has a prior history of severe nasal obstruction due to a traumatic injury to his nose. Examination reveals a significant septal deviation with inferior turbinate hypertrophy. He also has very hypertrophic tonsils. At this point, we will correct his nasal airway and also increase his oral airway by removing his tonsils and see if that will help his sleep apnea. If there is any residual sleep apnea, he may be treated with nasal CPAP (continuous positive airway pressure) or, if he is unable to tolerate that, further airway expansion surgery.

DESCRIPTION OF PROCEDURE: After parental consent was obtained, the patient was taken to the operating room and placed on the operating table in the supine position. After an adequate level of general endotracheal anesthesia was obtained, the patient was turned and draped in the appropriate manner for nasal surgery. The patient’s nose was packed with cotton pledgets and soaked with 4% cocaine. After several minutes, 1% Xylocaine with 1:100,000 units epinephrine was infiltrated into the septum bilaterally. It was also infiltrated into the inferior turbinates bilaterally. The nasal hairs were trimmed. Then, utilizing a right hemitransfixion incision, the mucoperichondrium and mucoperiosteal flaps were elevated. The deviated portion of the cartilaginous bony septum was then removed. Spurs off the maxillary crest were also removed. Hemostasis was achieved with suction cautery along the maxillary crest and then with FloSeal. Attention was then focused on the inferior turbinate. The anterior mucosa was treated with a radiofrequency needle to 500J on each side. The hemitransfixion incision was then closed with interrupted 4-0 chromic suture. A quilting suture of 4-0 plain gut was then performed. Silastic splints were then placed on both sides of the nasal septum and secured with nylon suture. The nose was then packed bilaterally with nasal packs, which consisted of Merocel sponge covered with a gloved finger coated with Bacitracin ointment. This was inflated with local solution. The patient was then repositioned for tonsillectomy. The McIvor mouth gag was placed, allowing visualization of the tonsil. Attention was first focused on the left tonsil. The Dean retractor was placed in the superior pole, and tonsil was retracted toward the midline. Then, utilizing a harmonic scalpel at power level III, the tonsil was removed in its entirety from a superior-to-inferior direction. Hemostasis was achieved from spot suction cautery. The similar procedure was then performed on the right tonsil. The tonsillar fossa was then irrigated with saline. There was no bleeding. Tension of the mouth gag was then released. Reinspection showed no active bleeding. The anterior and posterior pillars of the superior aspect of the tonsillar fossa were then reapproximated with interrupted 3-0 chromic suture and figure-of-eight closure. Subsequent reinspection showed no active bleeding. Mouth gag was then removed. Prior to removal of mouth gag, 1% Xylocaine with 1:100,000 units epinephrine was infiltrated into the retromolar and soft palate areas bilaterally. The patient tolerated the procedure well. There was no break in technique. The patient was extubated and taken to the postanesthesia care unit in good condition.

FLUIDS ADMINISTERED: 1800 cc of RL ESTIMATED BLOOD LOSS: Less than 50 cc

PREOPERATIVE MEDICATION: 1 g Ancef and 12 mg (milligram) Decadron IV (intravenous)

SERVICE CODE(S): ________________________________________

ICD-10-CM DX CODE(S): ___________________________

Answer 1

ICD-10-CM DX CODE(S):

1.018 ICD-10-CM Diagnosis Code J34.3

Diagnosis Index entries containing back-references to J34.3:

Change: Removal of hypertrophic turbinate, nasal J34.3

2. diagnosis code for deviated septum: 470

3. Tonsil Hypertrophy: J35.1

4. Chronic Tonsillitis: J35.01

5. Nasal turbinate hypertrophy: J34.3

6. Deviated Septum: J34.2

Service Codes:

1.CPT code for Septoplasty

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

30620 Septal or other intranasal dermatoplasty (does not include obtaining graft)

Only if the RF device were used to incise mucosa and resect submucosal soft tissue and/or bone, should CPT 30140 Submucous resection inferior turbinate, partial or complete, any method be reported.

2. CPT code for deviated septum repair:30520

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

3. Diagnosis Code for Hypertrophy of nasal turbinates: J34.3

4. CPT code for Tonsillectomy: 42826 over 12 years