How To Use CPT Code 30540

CPT 30540 describes the surgical repair of intranasal choanal atresia, a condition that causes blockage of the choana, a passageway from the nose to the upper throat. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 30540?

CPT 30540 is used to describe the surgical repair of intranasal choanal atresia. This procedure is performed by a healthcare provider to correct a blockage in the choana, which is the passageway that allows for breathing through the nose. The repair is done through an intranasal approach, where the provider inserts surgical instruments through the nostrils to access and repair the atretic plate in the nasal cavity.

2. Official Description

The official description of CPT code 30540 is: ‘Repair choanal atresia; intranasal.’

3. Procedure

1. The healthcare provider preps and anesthetizes the patient.
2. Using a nasal speculum, the provider exposes the nasal mucosa and atretic plate in the nasal cavity.
3. A decongestant is used to open the blocked nose.
4. The provider uses a diamond burr to drill the atretic plate.
5. The blocked choanal openings are punctured and enlarged.
6. A silastic stent is placed in each nostril to prevent further stenosis or blockage.
7. The stents are kept in place for up to eight weeks to ensure the patency of the newly created openings.

4. Qualifying circumstances

CPT 30540 is performed on patients with intranasal choanal atresia, a condition that causes blockage of the choana. The procedure is appropriate for both acquired and congenital cases. The patient must be prepped and anesthetized before the repair is performed. The provider must use an intranasal approach, accessing the atretic plate through the nostrils.

5. When to use CPT code 30540

CPT code 30540 should be used when a healthcare provider performs the surgical repair of intranasal choanal atresia through an intranasal approach. This code is specific to the repair of choanal atresia and should not be used for other nasal procedures.

6. Documentation requirements

To support a claim for CPT 30540, the healthcare provider must document the following information:

• Patient’s diagnosis of intranasal choanal atresia
• Details of the surgical repair procedure, including the use of an intranasal approach
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures or interventions performed during the same session
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 30540, ensure that the procedure meets the criteria for intranasal choanal atresia repair. Use the appropriate CPT code based on the approach used for the repair. For repairs performed through a transpalatine approach, use CPT code 30545. It is important to follow the specific guidelines provided by the payer and to accurately report the procedure performed.

8. Historical information

CPT 30540 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs an intranasal choanal atresia repair on a patient with a congenital blockage of the choana.
2. During a surgical procedure, a provider corrects an acquired choanal atresia using an intranasal approach.
3. A patient undergoes an intranasal choanal atresia repair to alleviate breathing difficulties caused by the blockage.
4. A healthcare provider performs an intranasal choanal atresia repair on a pediatric patient with a congenital nasal obstruction.
5. Using an intranasal approach, a provider surgically corrects a blockage in the choana of a patient with acquired choanal atresia.
6. A patient with intranasal choanal atresia undergoes a surgical repair to restore normal nasal breathing.
7. A healthcare provider performs an intranasal choanal atresia repair on an adult patient with a congenital nasal blockage.
8. During a surgical procedure, a provider uses an intranasal approach to repair a blockage in the choana of a patient with acquired choanal atresia.
9. A pediatric patient undergoes an intranasal choanal atresia repair to improve nasal airflow and breathing.
10. Using an intranasal approach, a provider surgically corrects a blockage in the choana of a patient with congenital choanal atresia.