MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
Endocrine System (60000 – 60699), pg 290 – 292 in CPT book
Nine glands in the endocrine system, however only 4 of them are in the Endocrine
subsection.
 Thyroid
 Parathyroid
 Thymus
 Adrenal
Note: Pituitary and pineal gland are located in the Nervous System section,
The pancreas is located in the digestive system, and the ovaries and testes in the
female and male Genital system subsection.
http://www.thyroidmanager.org/Chapter21/ch01s15.html
OPERATIVE TECHNIQUE FOR THYROIDECTOMY
M. Cremers - 2010
Page 1
MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
http://www.bing.com/search?q=glands+in+the+endocrine+system&form=QBLH&qs=n&s
k=&sc=1-30
Select “Hormones, Glands, Pancreas, Thyroid” You-Tube Video
http://kidshealth.org/PageManager.jsp?lic=1&article_set=53855&cat_id=20607
You have a variety of endocrine glands in different sizes and shapes located in different
parts of the body. You might be surprised to learn that the pituitary gland, which is about
the size of a pea, is the "master gland" of the endocrine system. It makes and releases
a bunch of hormones that control other glands and body functions. Tiny and tucked
beneath your brain, the pituitary helps you grow big by producing growth hormone.
Your thyroid gland is in your neck and it's shaped like a bowtie or a butterfly. It makes
hormones that are important for growth and it helps you stay alert and full of energy.
Your adrenal glands are really important to your body in times of trouble, like when
you're sick or under stress. Adrenaline, one of the adrenal gland hormones, gives you
the boost you need if you're being chased by a wild animal — or even your brother!
Insulin Is Essential
Your pancreas is your largest endocrine gland and it's found in your belly. The pancreas
makes several hormones, including insulin, which helps glucose, the sugar that's in your
blood, enter the cells of your body. Your cells need to be fueled with glucose to function,
like a car's engine needs gas.
Diabetes - It occurs when a person's pancreas doesn't make enough insulin. It's also an
endocrine problem if a kid isn't growing as quickly as expected because his or her
pituitary gland isn't making enough growth hormone.
M. Cremers - 2010
Page 2
MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
Coding Scenario
Preoperative Diagnosis: Thyroglossal duct cyst
Postoperative Diagnosis: Same
Name of Procedure: Sistrunk Procedure
Findings: Mass adherent to the thyroid, starting low in the neck, extending up into the
tongue base
Indications for the procedure: teenage male who had a midline neck mass excised that
was low in his neck. He had a history of a fistula that drained. After excision of the
mass, he healed; however the mass started draining again. Given patient’s prior
pathology, which was suspicious for thyroglossal duct cyst, the risks, benefits, and
rationale of the procedure were discussed and consent was signed.
Description of Procedure: The patient was brought to the operating room after
satisfactory induction of general anesthesia. A time out was performed. The patient
was identified and the procedure verified. The patient was prepped and draped in the
usual fashion. Xylocaine 1% with adrenaline was injected in the skin. An ellipse was
made at the primary original excision site. Dissection was carried up around this tract.
Sinus tract had formed. Gradually, it was dissected up away from the straps and up to
the hyoid bone. Stair-step incision was made over the hyoid bone. Dissection was
carried down onto the hyoid bone. The mass was identified. With the hypoid exposed,
cuts were done to free up the midline portion of the hyoid. Dissection was then carried
up into the tongue base. Gradually, the mass was found at the back of the tongue and
was removed. Tongue musculature was then reapproximated after the wound was
copiously irrigated. Straps were then also reapproximated. Inferiorly, the thyroid gland
was identified and is intact. With that performed, the skin was closed in layers with
Vicryl deep and running Monocryl for intracuticular suture. A vessel loop was placed as
a drain as well when the incision was closed. Pressure dressing was then applied. With
that performed, the procedure was complete. The patient was awoken and brought to
the recovery room in stable condition. The patient tolerated the procedure well without
any apparent complications.
CPT Procedure Code: 60280
Diagnosis: 759.2
Go through exercises 21:1 on page 629 SBS TB
M. Cremers - 2010
Page 3
MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
http://kidshealth.org/kid/cancer_center/HTBW/brain.html
Central Nervous and Peripheral Nervous System
 Includes the brain and spinal cord
 Peripheral nervous system contains 12 pairs of cranial nerves and 31 pairs of
spinal nerves. See Figure 21-3 on page 630 SBS TB
http://www.youtube.com/watch?v=cqvoV4R7T2g&feature=related
Nervous System (61000 – 64999) - procedures performed on the brain, spinal cord,
nerves, and all associated parts. Divided according to anatomic site and then by
procedure. Located Pg 293-295 CPT Index
M. Cremers - 2010
Page 4
MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
Tour of the Human Brain - by kids
http://library.thinkquest.org/J002952F/favorite.htm
How the Brain Works
http://health.howstuffworks.com/brain3.htm
http://www.edheads.org/activities/brain_stimulation/
Deep Brain Stimulation Surgery:
Help Dr. Vanessa Mei cut, probe and drill her way to helping her patient cope with a
movement disorder through brain surgery
Virtual Brain Surgery
This is one of the biggest and most realistic Edhead games with 5 separate steps.
You need to cure a woman who has an illness called Parkinson’s disease. She’s been
sick for a while and it makes her shake. The shakes are so bad that she can hardly sign
her own name.
The problem is deep down inside her brain and can only be fixed by opening up her
skull and placing an electrode in the area that is not working properly. The electrode will
deliver a small electric shock every so often to stimulate the brain and stop the shakes.
Surgery of Skull Base (61580 – 61619) (can use modifier -51 on these)
 Procedures are categorized according to approach (61580 – 61598)
o Anterior
o Posterior
 Where the procedure takes place (61600 – 61616)
o Base of Anterior Cranial Fossa
o Base of Middle Cranial Fossa
o Base of Posterior Cranial Fossa
 Repair/Reconstruction (61815 – 61816)
What code would you use to report burr hole(s) to drain an abscess of the brain?
A. 61253, 324.1
B. 61150, 324.0
C. 61156, 324.0, 041.11
D. 61151, 324.1
M. Cremers - 2010
Page 5
MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
Aneurysm, Arteriovenous Malformation, or Vascular Disease (61680 – 61711)
Categorized according to approach and method of procedure
Video of an Aneurysm Clipping Procedure
http://www.mayfieldclinic.com/PE-Clipping.htm
The patient was brought to the operating room to repair an aneurysm of the intracranial
artery by balloon catheter
A. 61698, 437.0
B. 61697, 437.4
C. 61710, 437.3
D. 61700, 437.1
Cerebrospinal Fluid Shunts (CFS) (62180 – 62258), pg 633 – 634 SBS TB
Shunt – draining device
M. Cremers - 2010
Page 6
MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
Spine and Spinal Cord (62263 – 63746)
 Deals with the condition and the approach
 62270 – lumbar puncture, pg. 636 SBS TB
 Can use the modifier -51 approach
 A sensory evoked study can also be billed – 95925
Lumbar puncture (pg. 636 SBS TB) – obtains cerebrospinal fluid by insertion of a
needle into the subarachnoid space in the lumbar region. Sometimes used on cancer
patients.
Virtual video of a spinal tap
http://www.virtualcancercentre.com/humanatlas1/vmc_white.asp?anid=0155
Click on the select a topic or click on related topic. More virtual video’s on back
surgeries.
Animated Lumbar Herniated Disc Surgery
http://www.spine-health.com/video/lumbar-herniated-disc-video
Operative Report: Herniated Disc
Procedure: Hemilaminectomy L4-5 and L5-S1
The patient was taken to the operating room prepped and draped in the usual fashion.
Once the lower back area was opened, after decompression of the nerve roots, the
interspace at L4-5 was entered and the disc fragment was excised. Next, the
interspace at L5-S1 was entered and disc fragments were excised as well. The patient
tolerated the procedure well.
A.
B.
C.
D.
63045, 63048, 722.2
63040, 63043, 839.00
63030, 63035, 722.10
63040, 63043, 722.10
M. Cremers - 2010
Page 7
MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
Preoperative Diagnosis: Obstructed ventriculoperitoneal shunt in patient with
obstructive hydrocephalus
Procedure Performed: Revision of shunt. Replacement of ventricular valve and
peritoneal end. Entire shunt replacement.
Procedure: Under general anesthesia, the patient’s head, neck, and abdomen were
prepped and draped in the usual manner. An incision was made over the previous site
where the then shunt had been inserted in the posterior right occipital area. This shunt
was found to be nonfunctioning and was removed. The problem was that we could not
get the ventricular catheter out without probably producing bleeding, so it was left
inside. The peritoneal end of the shunt was then pulled out through the same incision.
Having done this, I placed a new ventricular catheter into the ventricle. I then attached
this to a medium pressure bulb valve and secured this with 3-0 silk to the subcutaneous
tissue. We then went to the abdomen and made an incision below the previous site,
and we were able to trocar the peritoneal end of the shunt by making a stab wound in
the neck and then connecting it up to the shunt. This was then connected to the shunt.
Pumping on the shunt, we got fluid coming out the other end. I then inserted this end of
the shunt into the abdomen by dividing the rectus fascia, splitting the muscle, and
dividing the peritoneum and placing the shunt into the abdomen. One 2-0 chromic
suture was used around the peritoneum. The wound was then closed with 2-0 Vicryl, 20 plain in the subcutaneous tissue, and surgical staples on the skin. The stab wound on
the next was closed with surgical staples. The head wound was closed with 2-0 Vicryl
on the galea and surgical staples on the skin. A dressing was applied. The patient was
discharged to the recovery room.
A.
B.
C.
D.
63740, 996.2, 331.3
62256, 996.56, 331.3
62160, 996.2, 331.5
62230, 996.2, 331.4
M. Cremers - 2010
Page 8
MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System (64400 –
64999), pg. 631 SBS TB
 Injection of Anesthesia (64600 – 64640, 64680 – 64681)
Cervical chemodenervation - 64613
Chemodenervation of muscle[s]; neck muscle[s] (e.g., for spasmodic torticollis,
spasmodic dysphonia] – Note: Watch description of injections as the code itself
indicates one or more injections. It may be in the same muscle site or different muscle
sites.
Botox Injection:
Established patient presents with recurring headaches. She reports that the headaches
started approximately 4 year ago and increased in frequency to the point where she
was having bad headaches daily and treating with over-the-counter headache
medications. The patients headaches increased to the point where she was in the
emergency room every 2-3 months. Symptoms included photophobia and
phonophobia, and “crushing” neck pain the neck and shoulder reason.
The patient returned to the neurologist with her headache schedule. The neurologist
ruled out medication overuse and other diagnostic possibilities as a cause of the most of
the headaches. The final diagnosis was migraine without aura. The neurologist orders
and provides direct supervision of a 100 mg Botox injection in the neck region. 3 botox
injections in various areas of the neck.
Administration of the Botox: 64613
Drug supply: J0585
Diagnosis: 346.00
 Neuroplasty (64702 – 64727)
o Divided up by site just like the Integumentary system
 Transection or Avulsion (64732 – 64772) – look for modifier -50
M. Cremers - 2010
Page 9
MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
Type of Nerve Blocks
Transforaminal Epidural Steroid Injection
CPT 64483, Fluoroscope – 77003-26
Diagnosis:
RADICULITIS, LUMBOSACRAL (724.4)
Patient has low back and leg pain lateral aspect and also back of the leg will do
the L5-S1 transforaminal if still has pain will do the S1 transforaminal on the right
side.
Procedure: RIGHT L5 transforaminal epidural steroid injection under fluoroscopy
After discussing the risks, benefits, and alternatives to the procedure, the patient
expressed understanding and wished to proceed. The patient was brought to the
fluoroscopy suite and placed in the prone position.
Procedural pause conducted to verify:
correct patient identity
procedure to be performed
(as applicable) correct side and site
correct patient position
availability of implants
special equipment or special requirements
After identifying theRIGHTL5 pedicle fluoroscopically with an oblique view, the skin was
sterilely prepped and draped in the usual fashion Betadine times three. The skin and
subcutaneous tissue were anesthetized with 1% lidocaine.
A 22-gauge 5" spinal needle was then advanced under fluoroscopic guidance to the
posterior superior aspect of the: RIGHT L5 neural foramen. Depth was gauged on
lateral view. Needle position at approximately the 6 o’clock position relative to the
pedicle was confirmed in the AP view. After negative aspiration, 1ml of contrast was
injected confirming epidural spread without evidence of intravascular or intrathecal
spread. A 3 ml solution consisting of 60 mg of Triamcinolone in 2 ml of 0.25%
bupivicaine was injected slowly and incrementally into the epidural space.
Following the injection the needle was withdrawn slightly and flushed with 1% lidocaine
as it was withdrawn. The patient tolerated the procedure well and there were no
apparent complications. After an appropriate amount of observation, the patient was
dismissed from the clinic in good condition under their own power
M. Cremers - 2010
Page 10
MEDICAL BILLING AND CODING
Endocrine and Nervous System
CHAPTER 21
Neuroplasty – Surgery to repair or restore nerve tissue
Type of Neuroplasty is Carpel Tunnel Release. Pg 640 SBS TB
92557 – Comprehensive Hearing Test (combination code – 92556 & 92553) – have to
do air and bone in order to do the combination code.
92567 – Tympanogram
The patient reported decreased left ear hearing.
Objective: The pure tone thresholds for the left ear indicated a gently sloping mild to
moderately severe sensorineural hearing loss. The right ear thresholds indicated a flat
mild sensorineural hearing loss through 2000 Hz with a rising moderate to mild
sensorineural hearing loss above 2000 Hz. The word recognition score for the left ear
was fair at an elevated presentation level and the right ear word recognition score was
excellent an elevated presentation level. The tympanograms for both ear(s) were
essentially normal. Both ear canals were free of cerumen by otoscopy.
Assessment: The audiological results were consistent with a bilateral sensorineural
hearing loss, L > R.
M. Cremers - 2010
Page 11