Clinical Indicators
Septoplasty

Procedure CPT FUD
Septoplasty or submuccous resection, with or without cartilage scoring, contouring or replacement with graft 30520 90

Indications

1. History...one or more required

a) Nasal airway obstruction or difficult nasal breathing causing any of the following: mouth breathing; snoring; sleep apnea; or recurrent sinus infections.
b) Frequent nosebleeds.
c) Atypical facial pain of nasal origin. Positive response to topical anesthetic, where deformed septum contacts a turbinate, supports but may not prove septal cause.
d) Asymptomatic deformity that prevents surgical access to other intranasal or paranasal areas, e.g., sinuses, turbinates.

2. Physical Examination... all appropriate findings required.

a) Description of complete intranasal exam.
b) Document absence of nasal polyps, tumors, turbinate hypertrophy or other causes of obstruction.
c) Identification of known or suspected bleeding site if the purpose of surgery is to control epistaxis.
d) Identification of sinus that is recurrently infected if the purpose of surgery is to control disease.
e) Description of nasopharynx, oropharynx, hypopharynx, and larynx if purpose of surgery is to treat sleep apnea or snoring.
3. Tests... optional
a) Nasal impedance (rhinometry).
b) Rhinomanometry.
c) Nasal endoscopy.

Postoperative Observations
1.  Bleeding?
2.  Pain?
3.  Packing or internal splint optional--is it in desired location?

Outcome Review
1. One Week

a) Healing--Did patient require treatment for bleeding, septal hematoma, or infection?

2. Beyond One Month

a) Presenting problem--Is it (see history) improved?
b) Status of septum--Is septal configuration desirable? Is there a perforation?

Associated ICD-9 Diagnostic Codes

470 Deviated nasal septum
738.0 Acquired congenital deformity of nose
748 Choanal atresia
748.1 Other congenital anomalies of nose
754.0 Congenital musculoskeletal deformities of skull, face, and jaw
781.1 Disturbances of taste and smell
784.7 Epistaxis
802 Closed fracture nasal bones
802.1 Open fracture nasal bones

Additional Information

Assistant Surgeon -- N
Supply Charges -- N
Prior Approval -- N

Anesthesia Code(s)
00160

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 to permit adequate examination of the inside of the nose for treatment of polyps, inflammation, tumors, or bleeding. When the nasal septum is deformed, there is no medicine that will cause it to be straightened, so surgery is the only solution to this problem. The undesirable results that may occur include a hole in the septum, failure to completely improve breathing, postoperative bleeding (usually easy to control), nasal crusting, and very rarely, a change in appearance.

Important Notice

The Clinical Indicators for Otolaryngology--Head and Neck Surgery are guidelines only. In no sense do they represent a standard of care. The applicability of an indicator for a procedure, and/or of the process or outcome criteria, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these guidelines will not ensure successful treatment in every situation.

The American Academy of Otolaryngology-Head and Neck Surgery, Inc. 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.

© 2000 American Academy of Otolaryngology-Head and Neck Surgery. One Prince Street, Alexandria, VA 22314.