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The procedure described by CPT® Code 30000 involves the drainage of an abscess or hematoma located within the nasal cavity, utilizing an internal approach. This means that the healthcare provider makes an incision inside the nose, allowing direct access to the affected area without external incisions. The procedure is essential for alleviating symptoms associated with the accumulation of pus or blood, which can cause pain, swelling, and potential infection. During the drainage process, the provider carefully navigates through the soft tissue to reach the abscess or hematoma, ensuring that the integrity of surrounding structures is maintained. If the procedure is performed for an abscess, the provider will break up any loculated areas within the abscess using blunt dissection techniques, which involve gently separating tissue without cutting. In cases where a hematoma is present, the provider will remove any clotted blood using suction to clear the cavity. Following the drainage, the cavity is typically flushed with saline or an antibiotic solution to promote healing and reduce the risk of infection. It is important to note that this code is specifically used when the abscess or hematoma is located in the internal nasal cavity, excluding the nasal septum, which is coded differently under CPT® Code 30020.
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The procedure described by CPT® Code 30000 is indicated for the following conditions:
The procedure begins with the patient positioned comfortably, and local anesthesia may be administered to minimize discomfort. The healthcare provider then makes an incision inside the nasal cavity, which allows access to the abscess or hematoma. This incision is carefully placed to avoid damaging surrounding structures. Once the incision is made, the provider dissects through the soft tissue to reach the abscess or hematoma. If the procedure is for an abscess, the provider will identify any loculated areas within the abscess and utilize blunt dissection techniques to break them up, ensuring that all pus is adequately drained. In cases of hematoma, the provider will use suction to remove any clotted blood, effectively clearing the cavity. After the drainage is complete, the provider flushes the abscess or hematoma cavity with saline or an antibiotic solution to cleanse the area and promote healing. This step is crucial in reducing the risk of infection and facilitating recovery.
After the procedure, the patient may be monitored for any immediate complications, such as excessive bleeding or signs of infection. Instructions for post-procedure care typically include keeping the nasal area clean and avoiding any activities that may increase pressure in the nasal cavity, such as heavy lifting or vigorous exercise. The patient may also be advised to avoid blowing their nose for a specified period to allow for proper healing. Follow-up appointments may be scheduled to assess the healing process and ensure that there are no complications. If antibiotics were prescribed, it is important for the patient to complete the full course as directed to prevent infection.
| Short Descr | DRAINAGE OF NOSE LESION | Medium Descr | DRAINAGE ABSCESS/HEMATOMA NASAL INT APPROACH | Long Descr | Drainage abscess or hematoma, nasal, internal approach | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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