How To Use CPT Code 30545

CPT 30545 describes the surgical repair of choanal atresia, specifically using a transpalatine approach. 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 30545?

CPT 30545 is used to describe the surgical repair of choanal atresia, a condition where there is a blockage of the choana, the passageway from the back of the nose to the upper throat. This code specifically refers to the repair performed through a transpalatine approach, which involves making an incision in the roof of the mouth to access and repair the blockage.

2. Official Description

The official description of CPT code 30545 is: ‘Repair choanal atresia; transpalatine.’

3. Procedure

1. The provider begins by making a U-shaped incision over the palate mucosa and continues down to the bony palate.
2. Using an elevator, the provider raises the mucosal flaps without entering the nasopharynx.
3. A diamond burr is then used to drill and remove the obstructive palatine bones posterior to the greater palatine foramina, the atretic plates, and the posterior vomer.
4. The provider punctures and enlarges the blocked choanal openings and places a silastic stent in each nostril to prevent further stenosis or blockage.
5. The mucosal incision is closed in a single layer, and the stents are kept in place for up to 8 weeks to ensure the patency of the newly created openings.

4. Qualifying circumstances

CPT 30545 is performed on patients with choanal atresia, a condition that causes a blockage in the choana. The procedure is done by a provider through a transpalatine approach, which involves making an incision in the roof of the mouth. This code should only be used when the repair is performed using this specific approach.

5. When to use CPT code 30545

CPT code 30545 should be used when a provider performs a surgical repair of choanal atresia using a transpalatine approach. It should not be used for repairs done through other approaches, such as the intranasal approach. This code is specific to the transpalatine approach and should only be reported when this approach is used.

6. Documentation requirements

To support a claim for CPT 30545, the provider must document the following information:

• Patient’s diagnosis of choanal atresia
• Details of the transpalatine approach used for the repair
• Date of the procedure
• Specific steps performed during the procedure, including the removal of obstructive bones and the placement of silastic stents
• Duration of time the stents will be kept in place
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 30545, ensure that the procedure is performed using a transpalatine approach. Do not report modifier 63 in conjunction with this code. It is important to note that CPT 30545 should not be reported with CPT codes 30540 or 30545. Additionally, consider the range of repair procedures on the nose (30400-30630) when selecting the appropriate code for the specific procedure performed.

8. Historical information

CPT 30545 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 provider performs a transpalatine repair of choanal atresia on an infant with a complete blockage of the choana.
2. Using a transpalatine approach, a surgeon repairs choanal atresia in a teenager with a partial blockage of the choana.
3. A provider performs a transpalatine repair of choanal atresia on an adult with a congenital blockage of the choana.
4. Using a transpalatine approach, a surgeon repairs choanal atresia in a young child with a acquired blockage of the choana.
5. A provider performs a transpalatine repair of choanal atresia on an elderly patient with a recurrent blockage of the choana.
6. A surgeon uses a transpalatine approach to repair choanal atresia in a patient with a history of multiple sinus surgeries.
7. A provider performs a transpalatine repair of choanal atresia on a patient with a unilateral blockage of the choana.
8. Using a transpalatine approach, a surgeon repairs choanal atresia in a patient with a bilateral blockage of the choana.
9. A provider performs a transpalatine repair of choanal atresia on a patient with a history of chronic sinus infections.
10. Using a transpalatine approach, a surgeon repairs choanal atresia in a patient with a deviated nasal septum.