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Anatomy & Physiology of the Brain (Encephalon): Preparing for ICD-10-CM/PCS

© Irene Mueller EdD, RHIAMay 2, 2013

Review Brain Anatomy and Physiology for ICD-10-CM/PCS Coding Overlap of Circulatory and Nervous Systems Functions of Brain Components of Brain Cells of Brain Brain Nerves

ICD 10 CM Terminology ICD 10 PCS Terminology

Integrated into presentation

Objectives

Have you completed the Pre-Test????

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Connected through organ & bodily function control All body functions are regulated by brain through nervous

system W/o messages from brain, circulatory system does not

work Heart function & fluid circulation triggered by nervous

system Messages sent from the brain control both blood and

lymphatic parts of circulatory system Blood provides energy for brain

Brain = 2% of mass, uses 20% of energy Avg weight of adult brain is about 3 pounds

Overlap of Circulatory and Nervous Systems in Brain

Blood pressure and heart rate regulation Vagus nerve controls pumping of heart As heart pumps, blood moves through blood passageways

around body to organs Baroreceptors pass information about blood pressure to

brain so brain makes adjustments to heart rate

Dependent on each other to ensure homeostasis Nervous system may have control, but circulatory

system must relay information for adjustments Both systems need to function properly & work together

to ensure proper body functions

Examples of Overlap in brain

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Cerebral Arteries AKA Intracranical Middle Cerebral Anterior /Posterior

Communicating Anterior/Posterior

Cerebral Cerebellar Other specified

Precerebral Arteries AKA Extracranial Leading to cerebrum, but NOT in

cerebrum Right vs Left for coding Basilar artery Carotid (Common, Internal)

External does NOT feed brain)

Vertebral Other

Anterior spinal Auditory internal

Circulatory System Components of Brain

Basilar Internal carotid Vertebral artery

Circle of Willis

http://etc.usf.edu/clipart/15400/15496/bldbrnvessls_15496.htm

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Control Center of body

Maintains homeostasis (w/endocrine system)

Functions of Brain

http://etc.usf.edu/clipart/8100/8171/human_brain_8171.htm

Nervous system = 2 parts CNS = Brain and Spinal Cord (not part of this

webinar) Cerebrum, cerebellum, brain stem

PNS = Nerves and Ganglia Somatic – connect CNS with skeletal muscles and skin Autonomic – connect CNS with cardiac/smooth muscle

and glands

Nervous System Components of Brain

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Largest Part of brain Cortex = Gray Matter on surface

6 layers of nerve cell bodies Millions of cells

Cerebral White Matter Under cortex Myelinated axons of nerve cells Transmit in 3 directions

Association = within same hemisphere Commissural = from one hemisphere to other Projection = from cerebrum to other parts of CNS

Cerebrum (L, brain)

3 general functions Motor = Govern muscle movement

Sensory = Interpret sensory input Vision = 30 % of cortex Touch = 8 % Hearing = 3 %

Association = Emotional and intellectual processes

Functions of Cerebrum

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As brain grows, more gray matter Cortex folds on itself, creating

Gyri (AKA convolutions) Gk, gyro,circle Upfolds winding over surface

Fissures – Deep downfolds Sulci –sulcus /sul·cus/ (sul´kus) pl. sul´ci [L.] a groove, trench, or furrow shallow downfolds separating gyri

Cortex

http://www.nlm.nih.gov/medlineplus/traumaticbraininjury.html

Right and Left halves of brain Divided by Longitudinal Fissure Connected by Corpus Callosum

Large bundles of transverse nerve cell fibers Each hemisphere divided into 4 lobes

Frontal, Parietal, Temporal, and Occipital Fifth lobe = Insula

Oval region of cerebral cortex overlying extreme capsule, lateral to lenticular nucleus, buried in depth of the fissura lateralis cerebri(sylvian fissure)

Separated from the adjacent frontal, parietal, and temporal opercula by circular sulcus of insula.

Synonym(s): insular area, insular cortex, island of Reil

Hemispheres of Cerebrum

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L, - callous, hard AKA colossal commissure of brain

A tract of nerve fibers passing from one side to other of spinal cord or brain

Larger in women Can transfer data between R & L

hemispheres faster than men Woman’s intuition

Corpus Callosum

Lobes of Cerebrum

http://en.wikipedia.org/wiki/Lobes_of_the_brain

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Responsible for higher cognitive functions, including: Problem solving Memory Language Judgment

Spontaneity Motivation Impulse Control Social and Sexual

Behavior

Frontal Lobe Functions

Role in emotions Responsible for

Smelling Tasting Perception Memory Understanding music Aggressiveness Sexual behavior

Language areas of brain

Temporal Lobe Functions

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Broca’s area French surgeon, 1861 Frontal lobe Motor neurons Control of Speech

Wernicke’s area German pathologist, 1874 Temporal lobe Motor neurons Comprehension of

Language, Speech sounds

Language areas of Brain

http://www-rohan.sdsu.edu/~gawron/intro/course_core/lectures/aphasia_cases_slides.html

L. – uncus – hook From Gk onkos Hooklike anterior end of hippocampal gyrus

on temporal lobe of brain

Uncus

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Role in sensations of touch, smell, and taste Processes sensory & spatial awareness Key part of eye-hand co-ordination & arm

movement Wernicke’s area

Matching written words to sound of spoken speech

Parietal Lobe Functions

Controls vision and recognition Visual perception Color recognition

Receives visual input from retina Retina is part of brain

Visual signals are interpreted in occipital lobes Each optic nerve

has million fibers

Occipital Lobe Functions

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Sited below back of cerebrum

Transverse fissure separates from cerebrum

2 hemispheres separated by vermis

Both gray and white matter Connected to brain stem by

cerebellar peduncles (paired fiber bundles)

Cerebellum

http://etc.usf.edu/clipart/15500/15558/brainbase_15558.htm

Motor area of brain Controls unconscious movements in

skeletal muscles Coordination, Posture, Balance

Functions of Cerebellum

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Located below cerebrum & in front of cerebellum

Structures (from top to bottom) Thalamus Hypothalamus Midbrain Pons Medulla oblongata

Brain Stem

http://birthinjury.org/brain-injury-cerebral-palsy-tour-of-brain.html

Oval-Shaped, Large, Located above midbrain

Relays all sensory impulses (EXCEPT smell) to cerebral cortex “Gateway”

Interprets and produces conscious Pain recognition

Thalamus (Gk: Inner Room)

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Striped mass of white & grey matter located in front of thalamus in each cerebral hemisphere Consists of caudate nucleus and lenticular nucleus

Corpus striatum

Controls many homeostasis-relatedbody actions Controls Body temperature Regulates Biorhythms (Wake/Sleep) ANS – heartbeat, food movement, urinary

bladder Interprets viscera-based sensory impulses

Regulates food intake (Hunger/Satiety) Regulates fluid intake (Thirst)

Monitors/Works with endocrine system Responds to Mental states – Fear, etc.

Hypothalamus

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Connects Pons and Cerebellum Short, Constricted Origination of 2 Cranial Nerves

III – Oculomotor IV - Trochlear

Midbrain

Located anterior to Cerebellum, above Medulla

Bridge between spinal cord & Brain Connects other parts of brain as well Origination for 4 cranial nerves

V – Trigeminal VI – Abducens VII – Facial VIII –Vestibulocochlear

Pons (L. Bridge)

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Lowest part of brain Form upper part of Spinal Cord Main Conduction Pathways

2 pyramids - ventral aspect Motor tracts from cortex to cord Nerve fibers cross to other side Extrapyramidal = functional, not

anatomical, unit comprising nuclei & fibers (excluding pyramidal tract) involved in motor activities; control/coordinate especially postural, static, supporting, & locomotor mechanisms.

2 nuclei on dorsal aspect Receive sensory impulses from spinal cord

(ascending) Relay to OPPOSITE side of medulla

Origination for 4 cranial nerves IX – Glossopharyngeal X –Vagus XI – Accessory XII - Hypoglossal

Medulla oblongata

Reflex Centers

Cardiac – Regulates Heartbeat Respiratory – Rate and Depth of

Breath Vasoconstrictor – Regulates

Diameter of Blood Vessels

Medulla oblongata, cont.

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3 sets of paired bundles of hindbrain, connecting cerebellum to Midbrain (superior) Pons (middle) Medulla oblongata (inferior)

Cerebellar peduncles

L. tapeta - a carpet Layer of fibers of corpus callosum forming

roof of part of lateral ventricle

Tapetum of brain

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Pineal (L., Pine cone)

Pituitary L. - pītuītārius pertaining to/secreting phlegm

Glands in the Brain

Endocrine gland Source of melatonin

Hormone derived from tryptophan Regulates circadian rhythm (sleep cycle)

Located behind 3rd cerebral ventricle Midline of brain

Pineal Gland

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Master gland Central role in homeostasis,

maintaining reproductive cycle, directing activity of other glands Anterior, intermediate, and posterior lobes function as 3

separate endocrine organs Distinct cell populations, secretory products, & regulatory

mechanisms Anterior lobe secretes thyroid stimulating hormone, corticotropin,

luteinizing hormone, follicle stimulating hormone, growth hormone, and prolactin. Regulated by hypothalamus via portal vascular system

Posterior lobe releases oxytocin & vasopressin from axon terminals originating in cell bodies located in hypothalamus

Intermediate lobe rudimentary in humans, but produces several hormones (which are just now being studied).

Pituitary Gland

Thalamus Hypothalamus Cingulate gyrus Amygdala Hippocampus Basal Ganglia

Limbic System of Brain

http://en.wikipedia.org/wiki/Lobes_of_the_brain

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Regulates emotion and memory Directly connects lower & higher brain

functions Influences

Emotions Visceral responses to emotions Motivation and Mood Sensations of pain and pleasure

Limbic System Functions

Cingulate gyrus , L. - Girdle (surrounding), Gk. - Circle

Amygdala, Gk. – Almond (also used for tonsil)

Hippocampus, Gk. – seahorse

Basal Ganglia, Gk. - knot

Limbic System Components

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Part of cerebrum gray matter Surrounds, directly connected to parts of inner

Limbic System

Serves as conduit for messages to and from inner Limbic System

Cingulate gyrus

Makes associations across different modes of stimulus Smell of lilacs = visual memory of my house in Great

Falls

Appears responsible for influence of emotional states on sensory inputs Same stimulus = Different perceptions Sound of USAF Jets not noise – memory of childhood

Thought responsible for face recognition

Amygdala

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VERY important in transition of information from short to long term memory Search Engine of brain Learning and consciously remembering everyday

facts and events

Also part of Temporal Lobe Damage to that lobe can result in memory loss

Hippocampus

AKA Substantia nigra, Subthalmic nucleus Important in planning & coordinating motor

movements and posture Basal Ganglia linked with Cerebral Cortex via

complex neural connections Major effect of Basal Ganglia = Prevention of

unwanted muscular activity Basal Ganglia Disorders result in exaggerated,

uncontrolled movements

Basal Ganglia

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Network of connected cavities filled with cerebrospinal fluid (CSF)

2 Lateral Ventricles Third Ventricle Cerebral Aqueduct

AKA Aqueduct of Sylvius

Fourth Ventricle

Ventricles (Ependyma)

http://emedicine.medscape.com/article/1923254-overview

Choroid plexuses located in ventricles produce CSF, which fills ventricles & subarachnoid space Cycle of production and re-absorption (toxic wastes)

Buoyancy, Protection, & Chemical stability Protection = CSF in meninges protects brain from

striking cranium when head jolted Buoyancy = CSF and brain have similar density, so

brain is suspended neutrally, allowing growth without sitting on bone

CSF has protein, glucose, electrolytes, etc 500 ml per day, space for 130 ml in system

Functions of Ventricles

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Protect brain and spinal cord 3 membranes

Dura mater = Outermost, tough, thick, fibrous Arachnoid = Middle, delicate, fibrous Pia Mater = Inner, transparent, tender

Contains blood vessels Only layer that adheres to brain surface

Leptomeninges – 2 innermost; CSF circulates between them Gk – Small, thin

Meninges

CELLS OF THE BRAIN

http://www.ninds.nih.gov/disorders/brain_basics/ninds_neuron.htm

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100 billion neurons (nerve cells) Sensory (afferent) – messages TO brain Motor (efferent) – messages FROM brain

Trillions of Glia (Gk: Glue) (glial cells) AKA Neuroglia Connective tissue of brain 4 main types

Astrocytes, ependymal cells, microglia, oligodentrocytes

Common tumors of nervous system

Cells of Brain

Sensory neurons carry information from sense organs (such as eyes and ears) to brain

Motor neurons control voluntary muscle activity (ex: speaking) carry messages from nerve cells in brain to

muscles

All other neurons are Interneurons

3 classes of neurons

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Cell body - includes nucleus, cytoplasm, and cell organelles Nucleus has DNA & information needed for growth, metabolism, and repair Cytoplasm = substance filling cell, including all chemicals/parts needed for cell

to work properly Cell organelles = small structures (chromosomes, Golgi bodies, etc.)

http://library.thinkquest.org/12413/structures.html

Dendrites Branch from cell body, act as point of contact for receiving impulses

(chemical/electrical signals) from neighboring neurons

Axon Sends impulses, extends from cell body to meet/deliver impulses to another

nerve cell Range in length from fraction of inch to several feet Sciatic nerve axons extend from buttock to top of foot

Neurons - 3 basic parts

Microglia = Brain’s immune system Schwann cells/Oligodendrocytes form insulating

sleeves around neurons to keep electric signals from diffusing (Myelin)

Radial glia in developing brain After helpng neurons move around Then become astrocytes

Ependymal cells (ependymocytes) Cells lining central canal of spinal cord (pyramidal

shape) or brain ventricles (cuboidal shape) Produce/absorb/move (cilia) CSF

Types of Glia cells

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Insulating material wrapped around axons Complex mixture of proteins and fats Nodes of Ranvier – gaps in myelin Electrical signal jumps from node to node

Increases conduction speed of electrical signals along nerve fibers to muscle

Made by Glial cells Oligodendrocytes in CNS Schwann cells in PNS

Myelin

http://frcables.blogspot.com/

Transmission electron micrograph of a myelinated axon, generated at the Electron Microscopy Facility at Trinity College, Hartford, CT

Have starlike rays Reach out in all directions

Most abundant type of glial cells So, most abundant of all brain cells

One astrocyte can wrap its rays around a million+ synapses

Astrocytes fuse together Conduits for molecules moving from cell to cell

Astrocytes

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Cells in Cerebrum generate electrical potentials Pass thru skull; Can be detected by electrodes EEG = recording/graph of brain waves

Beta - consciously alert, or feeling agitated, tense, afraid Frequencies from 13 to 60 pulses/second in Hertz scale

Alpha - state of physical and mental relaxation, but aware of surroundings Frequencies around 7 to 13 pulses/second

Theta - state of somnolence w/reduced consciousness +/- 4 to 7 pulses/second

Delta - unconsciousness, deep sleep or catalepsy 0.1 to 4 cycles/second

Brain Waves

http://en.wikipedia.org/wiki/Epilepsy

NERVES OF THEBRAIN

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Cranial Nerves

http://en.wikipedia.org/wiki/Cranial_nerve

AKA Auditory

ICD-10-CM Indexuses numerical order (first,

fourth, etc), but also provides names

ICD-10-PCS uses NAMES only

IX

X

XI

XII

VIII

V

VIVI

III

IV

I

II

Only First and Second Cranial Nerves originate in Cerebrum

On Old Olympus’ Towering Top A Famous Vocal German Viewed Some Hops.

On Old Olympic Towering Tops A Finn And German Viewed Some Hops

OLd OPie OCcasionally TRies TRIGonometry And Feels VEry GLOomy VAGUe And HYPOactive

Some Say Marry Money, But My Brother Says Big Business Makes Money

Some say my mother bought my brother some bad beer, my, my S= Sensory, M = Motor, B = Both

Mnemonics for Cranial Nerves

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Some Lovers Try Positions That They Can't Handle!!!

Scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate

Bonus Mnemonic for MS

Chemicals that run brain 60+ affect memory, learning, relationships Thoughts, Food, Drugs effect brain chemicals

Stored in sacks near synapse at end of axon Electrical charges from cell body free

chemicals, propel them across synapse Special receptors at end of dendrites form to

accept certain neurotransmitters

Neurotransmitters

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Serotonin Aids in smooth transmission

of messages in brain/body Large role in regulating mood,

appetite, memory & learning Lack of serotonin may result

in low self-esteem, depression, aggression

Dopamine Helps information flow to

higher brain levels Key role in regulating

pain/pleasure Melatonin

Related to wake/sleep cycles

Epinephrine Moving body when needs instant

action, - fear/danger Acetylcholine

Enhances memory (chemical responsible for many dreams)

Endorphin (neuropeptide) Body’s natural pain killer -lots of

endorphin can create euphoric feelings

Cortisol (neuropeptide) Released when under stress Can be dangerous at high levels –

interrupts transmission of messages from neuron to neuron

Important Neurotransmitters

Laterality Specific Arteries Site

Must use proximal branch for nerve that does not have separate body part value in ICD-10-PCS

Ex: mandibular nerve is branch of trigeminal nerve, only the trigeminal nerve has a body part value When procedure performed on mandibular nerve, must

assign trigeminal nerve for body part value

Documentation Requirements for Coding

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Alphabetical listing of body parts shows PCS Description to use with Table Rows when constructing a ICD-10-PCS code

Artery/Nerve Families, etc. (ICD-10-PCS Body Key)

Anatomical Term PCS Description

Caroticotympanic artery Internal Carotid Artery, R/L

Carotid sinus nerve Glossopharyngeal nerve

Leptomeninges Cerebral/Spinal meninges

Mammillary body Hypothalamus

Middle cerebral artery Intracranial artery

QUESTIONS?

http://www.nimh.nih.gov/health/educational-resources/brain-basics/nimh-brain-basics.pdf

Homework

1. Review Powerpoint before taking post-test

2. Go online to at least two of the Resource sites with Games and/or Quizzes and see what A&P about the brain you have learned/reinforced

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Amar AP, Weiss MH. Pituitary Gland Anatomy and Physiology. Abstract. Neurosurg Clin N Am. 2003 Jan;14(1):11-23, v. http://www.ncbi.nlm.nih.gov/pubmed/12690976?report=abstract

Anatomy of the Brain. American Association of Neurological Surgeons. http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments

/Anatomy%20of%20the%20Brain.aspx

Anatomy of the Brain and Skull. Philips Medical Games. http://www.theonlinelearningcenter.com/free-medical-games/AP001/anatomy-

physiology-brain-skull.html

Brain Anatomy. Game. http://www.purposegames.com/game/brain-anatomy-quiz

Brain Anatomy and Functions. Tutorial and Quiz. Getbodysmart. http://www.getbodysmart.com/ap/nervoussystem/cns/brain/menu/menu.html

Resources

Cliff Notes. Anatomy & Physiology. Well-organized and includes quizzes. http://www.cliffsnotes.com/study_guide/Anatomy-

Physiology.topicArticleId-277792.html Cranial Nerves: Review Info. Quizzes.

Cranial Nerves: Review Info http://www.gwc.maricopa.edu/class/bio201/cn/cranial.htm

Cranial Nerves Dirty Mnemonic Tutorial. Video. http://www.youtube.com/watch?v=LTUHTxWG6EQ

Crisan, E. Ventricles of the Brain. Jun 27, 2011. Medscape Reference. http://emedicine.medscape.com/article/1923254-overview

Resources

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Division of Disability and Aging Services. Vermont. Brain 101: The neurotypicalbrain. http://www.ddas.vermont.gov/ddas-policies/policies-tbi/policies-tbi-

documents/tbi-trng-modules-workbks/training-module-1-brain-101 Gray, H. Anatomy of the Human Body. 1918.

http://www.bartleby.com/107/ Human Brain Anatomy. Study and Quiz Modules.

http://www.psych.ualberta.ca/~ITL/brain/ Interactive Tour of the Brain. National Brain Tumor Society.

http://www.braintumor.org/patients-family-friends/about-brain-tumors/index8.html

Intro to the Brain. ITS. San Diego State Univ. Includes Test. http://its.sdsu.edu/multimedia/mathison/index.htm

Kean, M. L. The Brain. Tutorial. http://www-

rohan.sdsu.edu/~gawron/intro/course_core/lectures/aphasia_cases_slides.html

Resources

Match a Brain. Game. http://www.anatomyarcade.com/games/matchingGames/MatchABrain/

matchABrain.html McGuire, N. ICD10 Session 11 Chapter 6. Codapedia. 32 Minute video.

http://codapedia.com/article_548_ICD-10-Session-11-Chapter-Six-Diseases-of-the-Nervous-System.cfm

Neuron-Glia Interactions in Nerve Development and Disease. http://www.ngidd.eu/public/index.html

NIMH. Brain Basics. http://www.nimh.nih.gov/health/educational-resources/brain-

basics/brain-basics.shtml Pineal Gland. Encyclopedia Brittanica.

http://www.britannica.com/EBchecked/topic/460967/pineal-gland

Resources

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Secret Life of the Brain. PBS. 3-D brain anatomy. http://www.pbs.org/wnet/brain/history/index.html

Tamarkin, D. A. Glia. http://faculty.stcc.edu/AandP/AP/AP1pages/nervssys/unit10/glia.htm

University of Bristol. How the Brain Works. Video, 6+ min. 2010. http://www.youtube.com/watch?v=9UukcdU258A

WebMD. Brain & Nervous System Health Center. http://www.webmd.com/brain/default.htm

WebMD. Medical References Related to Brain & Nervous System. http://www.webmd.com/brain/medical-reference-index

Wernicke area. Encyclopedia Britannica. Videos, Animations. http://www.britannica.com/EBchecked/topic/639879/Wernicke-area

Resources