Endocrine and Nervous Systems - Velocity Healthcare · Nervous System Procedures •Skull, Meninges, and Brain •Various methods may be used to pierce the skull and access the brain

Endocrine and Nervous Systems

Lamon Willis

Endocrine

Endocrine System - Anatomy

•Glands

•Secretory

•Excretory

•Hormones

Endocrine System - Anatomy

•Glands include:

• Thyroid

• Parathyroid

•Adrenal (medulla, cortex)

• Pituitary (anterior, posterior)

• Thymus

• Pineal

• Pancreas

Thyroid Gland

• Thyroid

• Lobes

• Isthmus

• T3 – triiodothyronine

• T4 – tetraiodothyronine or thyroxin(e)

•Calcitonin

Thyroid Gland

• Thyroid hormone

• Iodine

• TSH – thyroid stimulating hormone or thyrotropin

(pituitary)

•Goiter

•Calcitonin

Thyroid Gland

•Hyperthyroidism

•Graves’ disease

•Hypothyroidism

•Myxedema

•Cretinism

Parathyroid Glands

•Parathyroid hormone (PTH)

• 4 small glands

•Calcium

•Hypocalcemia

•Hypercalcemia

Thymus Gland

• Fetus

• Puberty

• Involution

• Lymphocytes, T-lymphocytes or T cells

• Thymosins

Adrenal Gland

•Adrenal or suprarenal

•Medulla

• epinephrine, norepinephrine

• pheochromocytoma

•Cortex

• zona: glomerulosa, fasciculata, reticularis

• glucocorticoids, mineralocorticoids, sex steroids

Adrenal Cortex

• Steroid hormones

•Glucocorticoids – cortisol

•Mineralocorticoids – aldosterone

• Sex hormones – estrogen, androgen

•Addison’s disease

•Cushing’s syndrome

Pancreas

•Endocrine

• Insulin

•Glucagon

•Exocrine

•Digestive enzymes

Pituitary Gland (hypophysis)

Anterior Pituitary

•Growth hormone, GH

• TSH

• FSH

• Prolactin

•ACTH

•MSH

•Hypothalamus controls hormone secretion

Posterior Pituitary

•Oxytocin

•ADH – vasopressin or

antidiuretic hormone

• diabetes insipidus

Pineal Gland

• Located above the cerebellum

•Deep in the brain

•Melatonin

• Biorhythm

• Sleep-wake cycle

•Maturation

Endocrine System Procedures

• Incision and drainage

– one code:

• 60000

• Excision: 60100-60281

60000 Drain thyroid/tongue cyst

60100 Biopsy of thyroid

60200 Remove thyroid lesion

60210 Partial thyroid excision

60212 Partial thyroid excision

60220 Partial removal of thyroid

60225 Partial removal of thyroid

60240 Removal of thyroid


60260 Repeat thyroid surgery


60280 Remove thyroid duct lesion

60281 Remove thyroid duct lesion


• Thyroid biopsies performed by percutaneous core

needle is reported with 60100.

• If a FNA (fine needle aspiration) is performed

instead of a core needle, the service is reported

with 10021 or 10022 not 60100.


• Thyroid lobectomies are reported based on

whether it is partial or complete.

• If a contralateral (opposite side) subtotal

lobectomy is performed during a partial

lobectomy, the service is reported with 60212.

• If a contralateral (opposite side) subtotal

lobectomy is performed during a complete

lobectomy, the service is reported with 60225.


•A thyroidectomy is the removal of the entire

thyroid.

•When this service is performed because of a

malignancy, the code is selected based on

whether a radial neck dissection is performed.

•A radial neck dissection will include removal of

the thyroid, lymph nodes, and sometimes nerves,

muscles, or veins.

Nervous System

Nervous System

•Neurons

•Cell body

•Dendrites

•Axons

•Myelin

• Synapses

Nervous System

•Neurotransmitters

•Glia, glial cells, neuroglia

•Astrocytes (astrocytoma)

•Dendrites

• Synapse

•Demyelination - MS

Nervous System

Nerve plexus or plexi

•Cervical

• Lumbar

•Brachial

• Sacral

•Coccygeal

Nervous System

•Central Nervous

System – CNS

• Brain

• Spinal cord

Nervous System

•Peripheral Nervous

System

•Cranial nerves

• Spinal nerves

Disorders

•Alzheimer’s disease

• Progressive

•Parkinson’s disease

•Dopamine

•Multiple sclerosis – MS

•Epilepsy

Brain

•Cerebrum

•Corpus callosum

•Cerebellum

•Brainstem

•Midbrain

• Pons

•Medulla oblongata

Brain

•Cerebrum (cerebral cortex)

•Cerebral hemispheres

• Frontal

• Parietal

• Temporal

• occipital

• Basal ganglia

Brain

•Occipital lobe

•Cerebellum

•Brainstem

•Medulla

• Pons

Brain

•Ventricles

•Choroid plexus

•Cerebrospinal

fluid - CSF

Brain

• Stroke

• Ischemic event

•Hemorrhagic stroke

•Aneurysm

• Transient Ischemic Attack -TIA

Spinal Cord

• Spinal nerves - motor and sensory fibers, dorsal

and ventral roots

•Cervical – 8

• Thoracic – 12

• Lumbar – 5

• Sacral – 5

•Coccygeal - 1

Spinal Cord

• Spinal nerves

• Interspace

•Disc

•Nucleus pulposus

•Annulus fibrosis

•Cartilage endplates

Peripheral Nervous System

Cranial Nerves

I Olfactory

II Optic

III Oculomotor

IV Trochlear

V Trigeminal

VI Abducens

VII Facial

VIII Vestibulocochlear

IX Glossopharyngeal

X Vagus

XI Accessory

XII Hypoglossal

Cranial Nerves (I-IV)

•Cranial nerve I – olfactory nerve

• Sense of smell; anosmia

•Cranial nerve II – optic nerve

•Vision

•Cranial nerve III – oculomotor nerve

•Cranial nerve IV - trochlear

Cranial Nerves (V)

•Cranial nerve V - trigeminal nerve

• 3 branches

• sensory

• ophthalmic

• motor – mastication

• Trigeminal neuralgia, tic douloureux

•neurodynia

Cranial Nerves (VI-VIII)

•Cranial nerve VI – abducens nerve

•motor nerve, controls eye movement

•Cranial nerve VII – facial nerve

• Facial expression

•Cranial nerve VIII – vestibulocochlear nerve

• Hearing and balance

Cranial Nerves (IX-XII)

•Cranial nerve IX – glossopharyngeal nerve

• Tongue sensation

•Cranial nerve X – vagus nerve

• Tongue, pharynx, larynx, chest & abdomen

•Cranial nerve XI – accessory nerve

•Cranial nerve XII – hypoglossal nerve

• Speaking, swallowing

Peripheral Nervous System (cont)

• Femoral

•Common fibular

• Intercostal

•Median

•Musculocutaneous

•Radial

• Saphenous

• Sciatic

• Subcostal

• Tibial

•Ulnar

Peripheral Nervous System (cont)

•Carpal tunnel syndrome

•Nerve entrapment

•Bell’s Palsy

•Mononeuritis

•Polyneuritis

Nervous System Procedures

• Skull, Meninges, and Brain

• Various methods may be used to pierce the skull and access the brain. These include:

• Twist drill holes for puncture (e.g., 61105–61108) and burr holes (e.g., 61120–61210).

• A trephine is a surgical instrument with a cylindrical blade, used to create an opening in the skull.

• The reason for access and location (for instance, for aspiration of hematoma or cyst, intracerebral) determine code selection.


•Craniectomy or craniotomy (61304–61576) is more

extensive than twist drill holes or burr holes.

•A section of skull, or bone flap, is removed to

access the brain underneath.

• If the bone flap is not replaced, the procedure is

called a craniectomy.

•Code according to the reason for the procedure

and its location.


• From the National Correct Coding Initiative (NCCI) edits manual:

• When this service (burr holes, twist holes, craniotomy, etc.) is integral to the performance of other services, CPT codes describing this service are not separately reportable if performed at the same patient encounter.

• A burr hole is separately reportable with another cranial procedure only if performed at a separate site unrelated to the other cranial procedure or at a separate patient encounter on the same date of service.”


• “In addition, taps, punctures, or burr holes

accompanied by drainage procedures (e.g.,

hematoma, abscess, cyst, etc.) followed by other

procedures are not separately reportable unless

performed as staged procedures.

• Many intracranial procedures include bone grafts

by CPT definition, and these grafts should not be

reported separately.”


•CPT provides extensive notes for skull base surgery

codes 61580–61619.

• These procedures are performed to treat lesions

involving the skull base, and consist usually of

three distinct parts:

1. Approach

2. Definitive Procedure

3. Secondary Repair


•Approach

• To find the appropriate skull-base surgery approach code, look to the surgeon’s documentation to determine the fossa targeted and whether the incision was through the dura.

•Confer with the surgeon to verify the exact structures he or she moved or removed to select the code that best describes the procedure.

• Note: Documentation in the medical record may not always match CPT code descriptor language.


• Definitive Procedure• The definitive portion of the procedure is determined

according to the area of the skull base (anterior, middle, or posterior cranial fossa) from which the surgeon performs the procedure.

• When coding for skull-base surgeries, the approach and definitive procedure codes should match. • An anterior approach (such as 61586) should accompany a

code describing, for instance, removal of a lesion in the same portion of the skull (the anterior cranial fossa).

• Other factors, such as whether the dura is entered, also will factor into code selection.


• Secondary Repair

• Often, the surgeon must perform a secondary repair following skull-base surgery.

• Report repair/ reconstruction codes (61618–61619) separately “if extensive dural grafting, cranioplasty, local or regional myocutaneous pedicle flaps or extensive skin grafts are required,” according to CPT guide lines.

• According to CPT, refer to the appropriate codes for primary closure, such as 15733, or a code from 15756–15758


•Endovascular Therapy

• Endovascular treatment of arterial disease of the

nervous system involves the use of balloons or

stents to treat a diseased artery.

• Procedures described by 61623–61651 generally

include selective catheterization of the target

vessel only.


•Codes 61623-61651 report cerebral endovascular therapeutic interventions in intracranial arteries.

• For correct coding, you must know the vascular territories:

➢right carotid circulation;

➢left carotid circulation; and

➢vertebro-basilar circulation.

•Codes 61623 and 61626 are the only OP procedures in for this code set.


• Surgery for Aneurysm, Arteriovenous (AV) Malformation, or Vascular Disease (inpatient)

• Codes 61680–61692 specify surgery of intracranial arteriovenous malformation.

• The malformation may be supratentorial (above the tentorium cerebella, or in the cerebrum), infratentorial (in the lower part of the brain or cerebellum), or dural(within the dura).

• These procedures may be coded as simple or complex, determined by accessibility and difficulty of repair.


• Aneurysm - a bulge or abnormal dilation caused by weakened blood vessel walls.

• Codes 61697–61703 describe repair of intracranial (within the skull) aneurysms.

• These repairs are classified as either simple or complex. • According to CPT, a repair is complex when the

aneurysm(s) is larger than 15 mm, involves calcification of the aneurysm neck (the constricted portion at the “base” of the aneurysm), incorporates normal vessels into the aneurysm neck, or requires temporary vessel occlusion, trapping, or cardiopulmonary bypass to complete the repair.


• The carotid circulation supplies blood to the anterior (front) and middle portions of the brain (via the carotid artery), and the vertebrobasilar circulation supplies the cerebellum and brain stem via vessels coming up the vertebral arteries.

•Code 61703 Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery (Selverstone-Crutch-field type) describes a unique procedure involving an approach through the neck to occlude the carotid artery to control bleeding.


• The surgeon performs a craniotomy and locates

the aneurysm. The ipsilateral carotid artery is then

occluded while the surgeon occludes the aneu-

rysm with a clip. Once bleeding is controlled, the

carotid clamp is removed, the dura is closed, and

the bone flap is repositioned and secured. The

scalp and neck incisions are closed.


•Codes 61705–61710 describe other techniques or

approaches for repairing intracranial vascular

abnormalities:

•A combined approach through the neck and skull;

the surgeon interrupts blood flow to the

abnormality in both directions (61705)

• Intracranial electrothrombosis (cautery) to

obliterate the lesion (61708)


• Intra-arterial embolization, injection procedure, or

balloon catheter (61710)

•Code 61711 Anastomosis, arterial, extracranial-

intracranial (e.g., middle cerebral/cortical)

arteries describes the joining of arteries to bypass

an aneurysm or other defect.


•Cranial Stereotaxis and Stereotactic Radiosurgery

•CPT provides extensive explanation and instruction

preceding stereotactic radiosurgery codes 61796–

61800.

• These services are all provided in an inpatient

setting.


•Cranial Neurostimulators

• Placement of intracranial neurostimulators is

reported using 61850–61888.

• These procedures include access by burr hole,

craniectomy, craniotomy, etc., and apply to any

type of intracranial neurostimulator (simple or

complex).

•Codes 61880-61888 are usually the only services

provided in an outpatient setting.


•Repair

•Codes 62000–62148 describe repairs to the skull.

• The code descriptors are straightforward.

• Follow CPT parenthetical notes, when applicable, for proper code selection.

•Neuroendoscopy

•Codes 62160–62165 describe procedures performed by neuroendoscopy in an inpatient setting.


•Cerebrospinal Fluid (CSF) Shunt

• Standard surgical treatment for hydrocephalus (an

accumulation of cerebrospinal fluid) includes

placement of an extracranial shunt, or tube, to

divert excess CSF from the ventricles of the brain to

another body area (most often the abdominal

cavity).

• The majority of the codes in this section apply to

services provided in an inpatient setting.


• Injection, Drainage, or Aspiration

•CPT supplies extensive notes prior to this

subsection, as well as numerous parenthetical

instructions.

•Read and understand these guidelines prior to

selecting a code.

•Highlights in this section include:


•During epidural lysis of spinal adhesions (Racz

catheter procedure or epidural adhesiolysis),

62263–62264, the surgeon inserts a needle near the

patient’s tailbone and threads a catheter through

the needle to inject medication into adhesions.

• These codes include the injection of contrast and

fluoroscopic guidance and localization.


•Code 62263 describes treatments spanning two or

more days, and is only reported once for the entire

series.

• Medicare considers this service an outpatient

service though CPT description says “2 or more

days.”

•Diagnostic spinal puncture (spinal tap) is reported

with 62270; therapeutic procedure for drainage of

CSF is reported with 62272.


•Report 62280 for all neurolytic injections or infusions

to the subarachnoid space, regardless of the

spinal level.

• For neurolytic injection or infusion into the epidural

space, choose between 62281 and 62282.


•When myelography is performed on the cervical,

thoracic, or lumbosacral regions utilizing a lumbar

injection, codes 62302–62305 are reported based

on the region under investigation and includes the

injection of contrast into the cervical, thoracic or

lumbar region of the spine and the radiological

supervision and interpretation.


• When two or more regions are being evaluated, code

62305 is reported.

• For non-neurolytic substances (anesthetic,

antispasmodic, opioid, steroid, etc.) administered

through single injection or via a continuous infusion or

intermittent bolus by indwelling catheter into the

epidural or subarachnoid space, select a code from

range 62310–62319, depending on the location.

• These codes include use of contrast material for

localization or epidurography.


• For transforaminal epidural injection of a non-

neurolytic substance, select from 64479–64484.

• For anesthetic injection of an anesthetic agent for

autonomic nerves, see 64505–64530.

• For paravertebral facet (zygapophyseal) joint

injections, report 64490–64495.

• Imaging guidance and localization are required

for these procedures, and are inclusive

components.


• If imaging is not used, report 20552–20553.

• If ultrasound guidance is used, report 0213T–0218T.


•Catheter, Reservoir/Pump Implantation• Procedures for “pain pumps” (for pain management or

spasticity treatment) are reported with 62350–62370.

• Available codes distinguish between programmable and non-programmable pumps.

• CPT parenthetical instructions provide guidance on coding for associated procedures, such as refilling and maintenance of implantable infusion pump.

• Codes 62369 and 62370 report analysis with reprogramming and refill, without or requiring the skill of a physician or other qualified healthcare professional


• Laminotomy, Laminectomy

• Laminectomy (excision of lamina and spinous

process) and laminotomy (partial excision of

lamina) are performed primarily for nerve

decompression.

•Read code descriptors carefully to determine if

related procedures, such as facetectomy,

foraminotomy, excision of herniated intervertebral

discs, etc., are included.


• These procedures are grouped according to

spinal region (cervical, thoracic, and lumbar).

• Some of these procedures are reported per

segment (e.g., 63015–63017), while others are

reported per interspace (e.g., 63020–63044).

•Generally, a single code is reported for the first

segment or interspace, with add-on codes used to

report additional segments or interspaces.


•Codes 63040–63044 specifically describe re-

exploration, or a repeat procedure.

• Follow CPT parenthetical instruction regarding

proper reporting of bilateral procedures and

allowable code combinations.


• Excision by laminectomy of lesion other than

herniated disc is reported using 63250–63290, as

appropriate to the type of lesion and its location.

•Add-on code 63295 describes reconstruction of

dorsal spinal elements following an intraspinal

procedure.

•CPT provides parenthetical notes outlining correct

use of this code.


•Extradural Exploration/Decompression

• Exploration and Decompression codes 63055–

63103 are grouped according to approach, which

also determines whether the procedure includes

removal of bone (for instance, vertebral

corpectomy).

•Read code descriptors carefully to determine if

related procedures, such as osteophytectomy,

etc., are included.


•Excision of Intraspinal Lesion, Anterior or

Anterolateral Approach

• These codes (63300–63308) are selected

according to spinal region (cervical, thoracic,

lumbar), whether intra- or extradural, and (in some

cases) by specific approach.

• These services are provided in an inpatient setting.


• Spinal Stereotaxis and Stereotactic Radiosurgery

• Stereotaxis may include:

• lesion creation (63600),

• stimulation not followed by other surgery (63610), and

• biopsy, aspiration, or excision of lesion (63615).

•CPT provides extensive explanation and instruction preceding 63620– 63621 for stereotactic radiosurgery.


• Spinal Neurostimulators

• Spinal cord stimulation delivers low voltage

electrical stimulation to the dorsal columns of the

spinal cord to block the sensation of pain. The

systems consist of electrodes implanted along the

spine, which are connected to a programmable

pulse generator or receiver.

• The electrodes may be either a catheter

electrode array, or arranged on a “paddle.”


• Implantation of electrodes is reported with 63650 or

63655, according to method.

• Two codes (63661, 63662) describe removal of spinal

neurostimulator electrodes, according to type

(electrode array or plate/paddles) and approach

(percutaneous or via laminotomy/laminectomy).

• Two additional codes describe revision (63663, 63664)—

including replacement when performed—of spinal

neurostimulator electrodes according to approach.

• All of the above include fluoroscopy if performed.


• Implantation or replacement of pulse generator

or receiver is reported 63685; revision or removal

of the same is reported 63688.

•Programming may be reported separately.


•Extracranial Nerves, Peripheral Nerves, and

Autonomic Nervous System

• This code section (64400–64495) applies to

extracranial nerves only; for intracranial surgery on

cranial nerves, see 61450, 61460, or 61790.


•Diagnostic or Therapeutic Nerve Block

•Nerve blocks are reported according to the

nerve/plexus targeted.

•CPT provides extensive parenthetical notes in this

section to guide code selection, and indicates

when associated procedures (such as image

guidance) may be reported separately.


• Transversus abdominis plane (TAP) blocks (64486–

64489) are reported based on whether the

procedure was performed unilaterally or bilaterally

and method of administration, either through

injections or continuous infusions.

• Imaging guidance is included if performed.

• These services are performed in an inpatient

setting.


• The term “facet joint injection” may describe

either a nerve block or more extensive nerve

destruction.

•When reporting nerve blocks (64490–64495), focus

on the “joint”—the area between adjacent

nerves—the provider targets; therefore, one nerve

block “level” will involve two nerves.

• For example, if the physician provides diagnostic

nerve blocks for C2, C3, and C4, he or she is


• For example, if the physician provides diagnostic

nerve blocks for C2, C3, and C4, they are

addressing three nerves but only two levels (the

joint at C2–C3 and the joint at C3–C4).

• Be sure to apply 64490– 64495 per level, rather

than per injection (the physician may provide

more than one injection per level).


•Codes 64490–64495 include imaging guidance

and describe unilateral procedures.

• If the provider addresses both the left and right

side at the same level, CPT guidelines allow

modifier 50 to report a bilateral procedure.


•Peripheral Neurostimulators

• Placement and revision/replacement of

peripheral nerve neurostimulators (simple or

complex) are reported using 64550–64595,

depending on the nerve targeted and type of

neurostimulator.


•Destruction by Neurolytic Agent

•Neurolytic agents for nerve destruction may

include chemical, thermal, electrical, or

radiofrequency methods.

•Codes in this range (64600–64681) are specific as

to the nerve(s)/plexus, muscle(s), or glands

targeted.


•When coding for nerve destruction, count the facet joints treated by the destruction of nerves.

• For codes 64633–64636, one facet joint may mean multiple nerves.

•Multiple injections in the same facet joint count as a single facet joint.

•Nerve destruction codes, like nerve block codes, describe unilateral procedures; report bilateral procedures using modifier 50 or modifiers LT and RT, as appropriate.


• The use of fluoroscopic guidance for needle

placement with either nerve block or nerve

destruction procedures is considered inclusive.

Note that paravertebral facet joint injections

(64490–64495) include image guidance

(fluoroscopy or CT).

• If imaging is not used, report 20550–20553.

• If ultrasound guidance is used, report 0213T–0218T.


•Neuroplasty

•Neuroplasty (64702–64727) describes

decompression and freeing of intact nerve(s) from

scar tissue.

• The codes are applied according to the nerve

targeted.


• Transection and Avulsion

•Codes for transection (to divide by transverse

incision) and avulsion (tearing away) of nerves

codes are selected according to the nerve

targeted.

•CPT parenthetical notes provide guidance for

proper reporting of bilateral procedures.


•Excision

• Excision of nerves is coded according to the nerve

targeted. Biopsy of a somatic nerve is reported

with 64795.

•Neurorrhaphy

•Neurorraphy is the surgical suturing of a divided

nerve. Codes in the range 64831–64876 describe

suturing only; the appropriate code is selected

according to the nerve(s) targeted.


•Codes 64885–64911 describe neurorrhaphy with nerve graft, vein graft, or conduit.

•Most codes are selected according to location (head or neck, hand or foot, etc.) and nerve length (more or less than 4 cm).

•Add-on codes 64901 and 64902 describe each additional nerve graft, single and multiple strands, respectively.

• If the surgeon repairs two or more nerves using grafts, report 64901– 64902, as appropriate.

Documents

Endocrine and Nervous Systems - Velocity Healthcare · Nervous System Procedures •Skull, Meninges, and Brain •Various methods may be used to pierce the skull and access the brain