April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery • July 2017

a bulbous tip. Nevertheless, patients with repaired cleft lip with or without cleft palate and nasal differences are generally accepting of residual imperfections, especially if their breathing has improved. Other possible adverse sequelae include saddle-nose deformity and nasal obstruction. Long-Term Outcomes Systematic reviews of the literature pertinent to correction of cleft lip nasal deformity have been reported in this Journal . 3,43 To date, thera- peutic evidence has been largely limited to level IV (case series) and level V (expert opinion). There is no level I evidence comparing the effec- tiveness of different techniques either in random- ized, controlled fashion or in multisite pragmatic trial fashion. One of the obstacles to collecting high-quality outcome data has been the lack of robust, validated outcome measures. 57 Prior pho- tographic rating scales, such as that described by Asher-McDade et al. and used in the Eurocleft and Americleft projects, 58 are criticized for being too subjective. More objective anthropometric, photogrammetric, and stereophotogrammetric techniques 59–66 have been criticized for being too complex and impractical. Validated patient- reported outcome measures have been shown to have great sensitivity for grading nasolabial appearance. The recently described CLEFT-Q, 67 for example, includes subscales for overall facial, labial, and nasal aesthetics, and for sagittal rela- tionship of the jaws. In the future, these patient- reported outcome measures may play a role in identifying what methods of secondary correc- tion of cleft lip nasal deformity are most effec- tive and at what age these interventions are best undertaken. Classification and Coding Current diagnostic coding schemes do not differentiate between unilateral and bilateral forms of cleft lip nasal deformity and do not characterize the severity of the nasal deformity. On October 1, 2015, the United States imple- mented an International Classification of Diseases, Tenth Revision –based system for diagnostic cod- ing, replacing the older International Classifica- tion of Diseases, Ninth Revision, Clinical Modification system. Table 2 summarizes the International Classification of Diseases, Tenth Revision, Clinical Modification codes related to cleft lip nasal defor- mity. In a typical clinical encounter, the surgeon or surrogate documents both the appropriate

cleft lip/palate diagnosis and the components of the nasal deformity. 53 Procedural coding in the United States con- tinues to be American Medical Association Cur- rent Procedural Terminology–based, which is summarized in Table 3. For various administra- tive purposes, hospital coders may need to con- vert the Current Procedural Terminology codes to International Classification of Diseases, Tenth Revision Procedure Coding System procedural codes. A discussion of International Classifica- tion of Diseases, Tenth Revision Procedure Coding System is beyond the scope of this review; how- ever, it is important to know that, to facilitate this code conversion, operative documentation should fully describe the nasal deformity (lat- erality and severity), timing and context of the repair (e.g., primary correction, intermediate correction, initial definitive rhinoplasty, or revi- sion rhinoplasty), approach (open or “closed”/ semiopen), and use of any devices/implants (including grafts). Although surgeons them- selves are unlikely to generate these complex procedural codes, this clinical information is required by administrators to perform the con- version behind the scenes. Table 3. Current Procedural Terminology Procedural Codes Commonly Used for Cleft Lip Nasal Deformity CPT Code Description 30460 Rhinoplasty for nasal deformity secondary to cleft lip and/or palate, including columellar lengthening; tip only Table 2. International Classification of Diseases, Tenth Revision, Clinical Modification Diagnostic Codes Relevant to Cleft Lip Nasal Deformity ICD-10-CM Code Description Q30.8 Maxillary hypoplasia ICD-10-CM, International Classification of Diseases, Ninth Revision, Clini- cal Modification. Other congenital malformations of nose Hypertrophy of nasal turbinates J34.3 M26.73

30462

Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction). Cartilage graft; nasal septum (do not use with 30462; may be used with 30460) Graft, bone; nose, maxillary or malar areas* Graft, rib cartilage, autogenous, to face, chin, nose or ear* Graft; ear cartilage, autogenous, to nose or ear*

30465

20912

21210 21230

21235

CPT, Current Procedural Terminology. *Includes obtaining graft.

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