Ch. 14: Endocrine and Nervous System

Question 1

What is the term for paralysis affecting one side of the body?

Answer 1

Hemiplegia
Response Feedback:
Rationale: Hemi is half. Hemiplegia is paralysis affecting one side of the body.

Question 2

What is a laminotomy?

Answer 2

a.
Partial excision of one or more lamina.

Response Feedback:
Rationale: A laminotomy is partial excision of a vertebral lamina (placing a hole in the lamina). It is also referred to as a hemilaminectomy. A laminectomy is complete excision of a lamina.

Question 3

What ICD-10-CM code is reported for Addisonian crisis?

Answer 3

c.
E27.2

Response Feedback:
Rationale: Look in the ICD-10-CM Alphabetic Index for Crisis/Addisonian directing you to E27.2. Verify code selection in the Tabular List.

Question 4

What are the four lobes of the brain?

Answer 4

c. Frontal, Parietal, Temporal, Occipital
Response Feedback:
Rationale: The four lobes of the brain are the Frontal Lobe, Parietal Lobe, Temporal Lobe, and Occipital Lobe.

Question 5

When coding for surgery performed on the Skull Base (61580-61598) what term describes the method used to gain exposure to the lesion?

Answer 5

a. Approach procedure
Response Feedback:
Rationale: The approach procedure is the method used to access the lesion. The approach procedure to the skull base is reported using codes 61580-61598. In the CPT® Index look for Skull Base Surgery and you will see that many of the subterms indicate Approach, with a code range of 61580-61598.

Question 6

A patient with a status post (after or following) lumbar puncture headache receives an epidural blood patch. The patient’s venous blood is injected into the lumbar epidural space; this blood forms a clot sealing the leak of CSF from the lumbar puncture. What CPT® and ICD-10-CM codes are reported?

Answer 6

c.
62273, G97.1

Response Feedback:
Rationale: In the CPT® Index look for Spinal Cord/Injection/Blood directing you to 62273.
In ICD-10-CM Alphabetic Index, look for Headache/lumbar puncture directing you to G97.1. Verification in the Tabular List confirms code selection.

Question 7

A patient with a neoplasm of the spinal meninges has a programmable pump implanted for chemotherapy administration. What CPT® and ICD-10-CM codes are reported?

Answer 7

d.
62362, C70.1

Response Feedback:
Rationale: In the CPT® Index look for Insertion/Infusion Pump/Spinal Cord directing you to code range 62361-62362. This is a programmable pump making 62362 the correct code selection. In ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/spine, spinal (column)/meninges and select from the Malignant Primary column directing you to C70.1. Verification in the Tabular List confirms code selection.

Question 8

A patient is receiving pain management treatment for chronic cervical pain caused by a motor vehicle accident. What ICD-10-CM code(s) and sequencing is/are reported?

Answer 8

a.
G89.21, M54.2

Response Feedback:
Rationale: In the ICD-10-CM Alphabetic Index look for Pain(s)/chronic/due to trauma directing you to G89.21. Cervical pain is found by looking in the Alphabetic Index for Pain(s)/neck NEC directing you to M54.2. According to the ICD-10-CM guideline I.C.6.b.1.b.ii when the treatment is for pain management, the chronic pain is listed first.

Question 9

The provider removes the thymus gland in a 27 year-old female with myasthenia gravis. Using a transcervical approach the blood supply to the thymus is divided and the thymus is dissected free from the pericardium and the thymus is removed. What CPT® code is reported for this procedure?

Answer 9

d. 60520
Response Feedback:
Rationale: Excision of the thymus gland is a thymectomy and is coded based on the approach. Code 60520 is for a transcervical approach, as documented. In the CPT® Index look for Thymectomy/Transcervical Approach.

Question 10

How is Streptococcal A Meningitis reported in ICD-10-CM?

Answer 10

a.
Streptococcal meningitis is reported first; Streptococcal, group A, as the cause of diseases classified elsewhere is reported second.

Response Feedback:
Rationale: Look in the ICD-10-CM Alphabetic Index for Meningitis/streptococcal (acute) directing the coder to G00.2. In the Tabular List, G00.2 has a note to use an additional code to further identify the organism. The organism is Streptococcus A. In the Alphabetic Index, look for Streptococcus, streptococcal/group/A, as cause of disease classified elsewhere directing the coder to B95.0. Verify all codes in the Tabular List.

Question 11

What is the ICD-10-CM code for a cavernous hemangioma in intracranial structures?

Answer 11

d. D18.02
Response Feedback:
Rationale: In the ICD-10-CM Alphabetic Index look for Hemangioma/cavernous/intracranial which directs you to D18.02. Verification in the Tabular List confirms code selection.

Question 12

A patient has a total thyroidectomy to remove thyroid cancer. Removal of all the lymph nodes along with the spinal accessory nerve, jugular vein and sternocleidomastoid muscles are performed to remove a malignant lymphatic chain. What CPT® and ICD-10-CM codes are reported?

Answer 12

b.
60254, C73

Response Feedback:
Rationale: In the CPT® Index look for Thyroidectomy/Total/for Malignancy/Radical Neck Dissection directing you to 60254. A radical neck dissection includes removal of all lymph nodes. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/thyroid (gland) and select from the Malignant Primary column directing you to C73. Verification in the Tabular List confirms code selection.

Question 13

A patient with chronic lumbago is seen by the provider to have an epidural injection of a non-neurolytic substance at the sacral level. What CPT® code is reported for this procedure?

Answer 13

d.
62322

Response Feedback:
Rationale: Documentation shows a single injection was given at the sacral level. Neither a catheter nor a device is documented as being used. In the CPT® Index look for Epidural/Injection or Epidural/Administration/Drug. Single injection codes are selected based on the level of the spine injected. 62322 is the correct chioce.

Question 14

A provider is performing an experimental cervical sympathectomy on a patient with Raynaud’s Syndrome. What CPT® and ICD-10-CM codes are reported?

Answer 14

b.
64802, I73.00

Response Feedback:
Rationale: In the CPT® Index look for Sympathectomy/Cervical, directing you to code 64802. There is no mention of this being a bilateral procedure, so modifier 50 is not warranted. In ICD-10-CM Alphabetic Index, look for Raynaud’s disease, phenomenon or syndrome and you are directed to I73.00. There is no mention of gangrene so you will not report I73.01. Verification in the Tabular List confirms code selection.

Question 15

What CPT® code is reported for a subtotal thyroidectomy for malignancy, with removal of only a few selected lymph nodes?

Answer 15

d. 60252
Response Feedback:
Rationale: The removal of all of the lymph nodes of the neck during a thyroidectomy is considered a radical neck dissection. When limited removal of all of the lymph nodes of the neck is performed, it is reported with 60252. The thyroidectomy is performed due to the patient having a malignancy. In the CPT® Index look for Thyroidectomy/Total/for Malignancy/Limited Neck Dissection.

Question 16

Operative Report
PROCEDURE: Left L3-L4 peri-articular paravertebral facet joint injection.
PATIENT HISTORY: The patient is a 67 year-old woman referred by Dr. X for repeat diagnostic/therapeutic spinal injection procedure. She is about 1 1/2 years status post lumbar decompression for stenosis. Two weeks ago she underwent an interarticular left L4-L5 paravertebral facet joint injection. She had no relief of symptoms from that injection.
TECHNIQUE: The patient was positioned prone and the skin was prepped and draped in the usual sterile fashion. The skin and underlying soft tissues were anesthetized with 3 cc of 1% lidocaine. Due to the advanced degenerative changes, the left L3-L4 paravertebral facet joint could not be distinctly visualized fluoroscopically, despite trying numerous angles. This was explained to the patient who wished to proceed with the injection. A 22-gauge 6-inch spinal needle was advanced toward the region of the left L3-L4 paravertebral facet joint under fluoroscopic guidance. Injection of 0.5 cc of Isovue 200 contrast showed the needle was not in an intravascular location.
Intra-articular placement could not be confirmed and the injection was presumed to be peri-articular. 2 cc containing equal parts preservative free 2% Lidocaine plus Depo-Medrol (80 mg per ml) was injected. The patient reported injection of medication produced discomfort in the region of her usual left low back pain. Immediately following the procedure, upon standing up from the procedure table, she reported her pain was a little bit better.
What CPT® code(s) is/are reported for this procedure?

Answer 16

c.
64493

Response Feedback:
Rationale: Nerve block injections are selected based on location and number of levels. Code 64493 is described as a paravertebral facet joint of lumbar spine, single level. This code descriptor includes imaging guidance, and it is not reported separately. In the CPT® Index look for Injection/Paravertebral Facet Joint/Nerve/with image guidance.

Question 17

PROCEDURES PERFORMED:

1. Bilateral facet joint injections, L4-L5
2. Bilateral facet joint injections, L5-S1.
3. Fluoroscopy.

TECHNIQUE: The AP view was aligned with the proper tilt so that the end plates for the desired levels were perpendicular. The AP image showed the sacrum and the L5 spinous process. Manual palpation located the sacral hiatus. The 6 inch, 20 gauge needle with a slight volar bend was inserted using fluoroscopy into each facet joint under AP image. The bilateral L4-L5, and L5-S1 facet joints were injected in a systematic fashion from caudal to cranial. A sterile dressing was applied. The patient tolerated the procedure well with no complications and was transferred to recovery in good condition.

Answer 17

d.
64493-50, 64494 x 2

Response Feedback:
Rationale: In the CPT® Index, look for Injection/Paravertebral Facet Joint/Nerve/with Image Guidance directing you to 64490-64495. Code selection is based on the location and the number of levels. The initial and one additional separate level lumbar facet joint injections performed bilaterally, at two levels, so use modifier 50 on facet injection codes 64493. Modifier 51 is not reported on add-on code 64494 because add-on codes are exempt from modifier 51. Add-on codes are also exempt from modifier 50. Report 64494 twice to indicate this was performed bilaterally. Depending on the payer, modifiers RT and LT may be appended. Fluoroscopy was utilized for all services and is bundles in codes 64490-64495 and not reported separately.

Question 18

A patient with primary hyperparathyroidism undergoes parathyroid sestamibi (nuclear medicine scan) and ultrasound and is found to have only one diseased parathyroid. A minimally invasive parathyroidectomy is performed. What CPT® and ICD-10-CM codes are reported for the surgery?

Answer 18

c.
60500, E21.0

Response Feedback:
Rationale: In the CPT® Index look for Parathyroidectomy or Parathyroid Gland/Excision directing you to code range 60500-60505. The parathyroidectomy is coded with 60500. Code 60502 is a re-exploration and code 60505 is used for a mediastinal exploration or transthoracic approach. In the ICD-10-CM Alphabetic Index look for Hyperparathyroidism/primary directing you to E21.0. Verification in the Tabular list confirms code selection.

Question 19

A patient with a malignant neoplasm of the spinal meninges is receiving a programmable pump implantation for chemotherapy. The patient is placed in the prone position where the provider made a midline incision overlying the area of the spinal cord. The reservoir was placed in the subcutaneous tissues and attached to the previously placed catheter. Layered sutures were used to close the incision. The patient tolerated the procedure well and was released in good condition. What CPT® and ICD-10-CM codes are reported for this procedure?

Answer 19

a.
62362, C70.1

Response Feedback:
Rationale: The procedure performed is implanting a programmable pump which allows the infusion of a medication (for example, chemotherapy) for treatment. For insertion or implantation of the pump, in the CPT® Index look for Infusion Pump/Spinal Cord directing you to codes 62361-62362. This is a programmable pump making 62362 the correct code selection. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/spine, spinal (column)/meninges and select from the Malignant Primary column directing you to C70.1. Verification in the Tabular List confirms code selection.

Question 20

Mrs. Marsden slipped on the ice last winter and fractured several lumbar vertebrae. Since then she has required pain management therapy at her local hospital with an anesthesiologist. He performs a therapeutic injection of 5% Marcaine mixed with the steroid Decadron (16mg) into the nerve located in the facet joints at levels L3-L4 and L4-L5 on both sides at each level using fluoroscopic guidance. What CPT® code(s) are reported for this procedure?

Answer 20

b.
64493–50, 64494 x 2

Response Feedback:
Rationale: Codes for the injection of an anesthetic and/or steroid are selected based on the location and number of levels. In the CPT® Index look for Injection/Paravertebral Facet Joint/Nerve/with Image Guidance directing you to 64490-64495. Code 64493 is for injection of the lumbar, single level L3-L4; and 64494 is the add-on code for the additional level L4-L5. Modifier 50 Bilateral Procedure is appended to code 64493 as the injection was on both sides. There is a parenthetical note above code above 64490 which indicates add-on code 64494 when performed bilaterally report it twice. Modifier 51 is exempt on add-on codes and not reported. There is a subsection guideline stating if imaging guidance is not used report 20552-20553.

Question 21

A patient recently experienced muscle atrophy and noticed she did not have pain when she cut herself on a piece of glass. The provider decides to obtain a needle biopsy of the spinal cord under ultrasound guidance in the outpatient setting. The biopsy results come back as syringomyelia. What CPT® and ICD-10-CM codes are reported for the biopsy procedure?

Answer 21

d.
62269, 76942-26, G95.0

Response Feedback:
Rationale: In the CPT® Index look for Biopsy/Spinal Cord/Percutaneous and you are directed to code 62269. Instructional note under code 62269 indicates for radiological supervision and interpretation, see 76942, 77002, and 77012. Ultrasound guidance for needle placement, 76942, can be separately billed. Modifier 26 is appended for the professional services. In the ICD-10-CM Alphabetic Index look for Syringomyelia directing you to code G95.0. Verification in the Tabular List confirms code selection.

Question 22

A 26 year-old patient presents with headache, neck pain and fever and is concerned he may have meningitis. The patient was placed in the sitting position and given 0.5 mg Ativan IV. His back was prepped and a 20-gauge needle punctured the spine between L4 and L5 with the return of clear fluid. The cerebrospinal fluid was reviewed and showed no sign of meningitis. What CPT® code is reported?

Answer 22

b.
62270

Response Feedback:
Rationale: In the CPT® Index look for Puncture/Spinal Cord/Diagnostic or Spinal Tap/Lumbar. 62270 is the correct code because a spinal puncture was performed without fluoroscopic or CT guidance in the lumbar region (L4 and L5). It was done to withdraw cerebrospinal fluid for testing to determine if the patient had meningitis (diagnostic).

Question 23

A 15 year-old is taken to surgery for crushing his index and middle fingers and injuring his digital nerves. The provider located the damaged nerves in both fingers and sutures them to restore sensory function. What CPT® codes are reported?

Answer 23

d.
64831, 64832

Response Feedback:
Rationale: Look in the CPT® Index for Suture/Nerve or Repair/Nerve/Suture. 64831 is the correct code to report the digital nerve was repaired. 64832 is the correct secondary code because there was an additional digital nerve repaired. Modifier 51 is not appended to the secondary code because this code is an add-on code and add-on codes are modifier 51 exempt.

Question 24

A patient with a right side, benign adrenal adenoma has a laparoscopic adrenalectomy. What CPT® and ICD-10-CM codes are reported?

Answer 24

c.
60650, D35.01

Response Feedback:
Rationale: In the CPT® Index look under Adrenalectomy/Laparoscopic and you are directed to 50545. 50545 is for a Radical Nephrectomy which includes an adrenalectomy. If you look for Adrenal Gland/Excision/Laparoscopy you are directed to 60650 which is listed as transabdominal, lumbar or dorsal, so this is the correct code choice. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/adrenal and select from the Benign column and you are directed to D35.0-. In the Tabular List the 5 th character selection determines laterality, reporting 1 for the right side.

Question 25

A 47 year-old male presents with chronic back pain and lower left leg radiculitis. A laminectomy is performed on the inferior end of L5. The microscope is used to perform microdissection. There was a large extradural cystic structure on the right side underneath the nerve root as well as the left. The entire intraspinal lesion was evacuated. What CPT® code(s) is/are reported for this procedure?

Answer 25

c.
63267, 69990

Response Feedback:
Rationale: In the CPT® Index look for Laminectomy/for Excision/Intraspinal Lesion/Other than Neoplasm directing you to code range 63265-63268 and 63270-63273. The code range is divided based on whether the lesion is extradural or intradural. In this case, it is extradural narrowing the range to 63265-63268. The range is further divided based on the location of the spine the lesion is located. Laminectomy with evacuation of an intraspinal lesion in the lumbar spine is described by code 63267. The use of a microscope is documented to perform microdissection. In the CPT® Index look for Operating Microscope directing you to 69990.