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Clinical Indicators: Septoplasty

Clinical Indicators: Septoplasty
Approach ProcedureCPTRBRVS Global Days
Septoplasty or submucous resection, with or without cartilage
scoring, contouring or replacement with graft
  1. History (one or more required)
    1. Nasal airway obstruction (unilateral or bilateral) causing any of the following: mouth breathing, snoring, nasal congestion, sleep apnea, unresponsive to medical management.
    2. Frequent nosebleeds, unresponsive to medical management, and for which deviation is a causative factor.
    3. Atypical facial pain of nasal origin. (Positive response to topical anesthetic, where deformed septum contacts a turbinate or lateral wall, supports, but may not prove, septal causation or contribution.)
    4. Asymptomatic deformity that prevents surgical access to other intranasal or paranasal areas, e.g., sinuses, turbinates.
  2. Physical Examination (all appropriate findings required)
    1. Description of complete intranasal exam.
    2. Document presence or absence of nasal polyps, tumors, turbinate hypertrophy, nasal valve compromise, or other causes of obstruction.
    3. Documentation of suspected bleeding site if the purpose of surgery is to control epistaxis.
  3. Tests… optional
    1. Nasal endoscopy.
    2. Computed tomography (CT)

Postoperative Observations

    1. Bleeding or septal hematoma?
    2. Pain?
    3. Packing or internal splint in the desired location and subsequently removed if placed?

Outcome Review

  1. One Week
    1. Healing–Did patient require treatment for bleeding, septal hematoma, or infection?
  2. Beyond One Month
    1. Presenting problem–Is it (see history) improved?
    2. Status of septum–Is septal configuration desirable? Is there a perforation?

Associated ICD-10-CM Diagnostic Codes (Representative, but not all-inclusive, codes)

  • J34.2 Deviated nasal septum
  • J33.8 Other polyp of sinus
  • J33.9 Nasal polyp, unspecified
  • J340 Abscess, furuncle and carbuncle of nose
  • J34.1 Cyst and mucocele of nose and nasal sinus
  • J34.89 Other specified disorders of nose and nasal sinuses
  • J34.9 Unspecified disorder of nose and nasal sinuses
  • R09.81 Nasal congestion
  • M95.0 Acquired deformity of nose
  • Q30.1 Agenesis and underdevelopment of nose
  • Q30.2 Fissured, notched and cleft nose
  • Q30.8 Other congenital malformations of nose
  • Q30.3 Congenital perforated nasal septum
  • Q30.9 Congenital malformation of nose, unspecified
  • R04.0 Epistaxis
  • S022XXA Fracture of nasal bones, initial encounter for closed fracture
  • S022XXB Fracture of nasal bones, initial encounter for open fracture
  • S022XXD Fracture of nasal bones, subsequent encounter for fracture with routine healing
  • S022XXG Fracture of nasal bones, subsequent encounter for fracture with delayed healing
  • S022XXK Fracture of nasal bones, subsequent encounter for fracture with nonunion
  • S022XXS Fracture of nasal bones, sequela

Patient Information

Septoplasty is an operation to correct a deformity of the partition between the two sides of the nose. The usual purpose is to improve breathing, but it may also be required as part of the management of polyps, inflammation, tumors, atypical facial pain, or bleeding. When the nasal septum is deformed and associated symptoms are present, there is no medicine that will cause it to be straightened, so surgery is the best solution to this problem. Uncommon side effects that may be associated with surgery include a hole in the septum, failure to completely improve breathing, postoperative bleeding (usually straightforward to control), nasal crusting or scarring, and very rarely, a change in appearance.

Important Disclaimer Notice (Updated 8/7/14)

Clinical indicators for otolaryngology serve as a checklist for practitioners and a quality care review tool for clinical departments. The American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Clinical Indicators are intended as suggestions, not rules, and should be modified by users when deemed medically necessary. In no sense do they represent a standard of care. The applicability of an indicator for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical indicators will not ensure successful treatment in every situation. The AAO-HNS/F emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. The AAO-HNS/F is not responsible for treatment decisions or care provided by individual physicians. Clinical indicators are not intended to and should not be treated as legal, medical, or business advice.

CPT five-digit codes, nomenclature and other data are copyright 2009 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

© 2012 American Academy of Otolaryngology-Head and Neck Surgery.

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