Rhinoplasty and Related Services

Nasal surgery is any procedure performed on the external or internal structures of the nose, septum or turbinate. This surgery may be performed to improve abnormal function, reconstruct congenital or acquired deformities, or to enhance appearance. When nasal surgery is performed to improve nasal respiratory function, correct anatomic abnormalities caused by birth defects or disease, or revise structural deformities produced by trauma, the procedure is considered reconstructive.

Rhinoplasty is a procedure that changes the shape or appearance of the nose while improving or preserving the nasal airway. The primary purpose for rhinoplasty can be functional, aesthetic, or both and may include other procedures on the paranasal sinuses, septum, or turbinates.

Septoplasty is a procedure used to correct deformities of the nasal septum which can often cause issues with airflow and difficulty breathing.

When nasal surgery is performed solely to improve the patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and noncovered under the Medicare program.

General Documentation Requirements

• Surgical plan of care supporting the procedure code requested as a service intended to be completed
• Medical documentation, with evaluation and management, supporting medical necessity of the service that is to be performed.
• Radiologic imaging if done.
• Photographs that document the nasal deformity (if applicable).
• Documentation supporting unresponsiveness to conservative medical management (if applicable) including the length of time utilized

Codes

The rhinoplasty and related services for the following CPT codes performed in an ambulatory surgical center (ASC) demonstration state or hospital outpatient department (HOPD) are subject to prior authorization (PA).

Note: Primary procedure codes are used for an initial intervention. Secondary procedure codes are reported if the patient has undergone the same procedure in the past.

Documentation Feedback

Rhinoplasty is considered medically reasonable and necessary when the procedure is performed for correction or repair of any of the following indications:

• Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial deformity causing a functional impairment.
• Chronic, non-septal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves).
• Secondary to trauma, disease, congenital defect with nasal airway obstruction that has not resolved after previous septoplasty/turbinectomy or would not be expected to resolve with septoplasty/turbinectomy alone.

Septoplasty is considered medically reasonable and necessary when performed for any of the following indications:

• Septal deformity/deviation causing nasal airway obstruction that has proved unresponsive to a recent trial of conservative medical management (e.g., topical nasal corticosteroids, nasal decongestants, nasal dilators). This includes nasal airway obstructions that interfere with the effective use of medically necessary continuous positive airway pressure (CPAP) for the treatment of an obstructive sleep disorder.
• Recurrent sinusitis secondary to a deviated septum that does not resolve after appropriate medical and antibiotic therapy.
• Recurrent epistaxis related to a septal deformity.
• Performed in association with cleft lip or cleft palate repair.
• For asymptomatic septal deviation/deformity that prevents access to other trans nasal areas when such access is required to perform a medically necessary procedure (e.g., ethmoidectomy).

References

• Billing and Coding: Cosmetic and Reconstructive Surgery (A58573)
• LCA: Cosmetic and Reconstructive Surgery L38914)
• Prior Authorization (PA) Demonstration for Certain Ambulatory Surgical Center (ASC) Services Operational Guide
• Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational Guide