Nervous system



Nervous system



The nervous system is divided into the sympathetic nervous system and the parasympathetic nervous system, as illustrated in Figures 12-1 and 12-2. A neurologist is a physician who treats and diagnoses conditions of the nervous system, including the spinal cord, brain, nerves, and muscles. Common neurologic disorders are dizziness, tremor, paresthesia (abnormal touch sensation), stroke, altered mental states, headache, seizure, sleep disorders, and neuralgia. The neurologist uses a variety of diagnostic tools, including magnetic resonance imaging (MRI), computed axial tomography (CAT or CT), electroencephalography (EEG), and EMG/NCV (electromyography/nerve conduction velocity). A neurosurgeon is a surgeon who specializes in surgical procedures or treatment of conditions of the nervous system, such as lumbar puncture, brain tumor, head injury, hematoma, and disc herniation.


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FIGURE 12–1 Sympathetic nervous system.

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FIGURE 12–2 Parasympathetic nervous system.


Twist drill or burr holes


Twist drill or burr holes are the opening of the brain to relieve pressure, to insert monitoring devices, or to place tubing or inject contrast material. The placement of these holes leaves the skull intact except for the hole, which is repaired at a later time. This procedure is also termed “trephine.” The CPT codes for these procedures (61105-61253) are based on the reason for the hole (such as implantation of catheter or pressure device, biopsy, aspiration of hematoma, etc.) and, in some instances, the location of the hole (such as supratentorial or infratentorial). The tentorium is a tented sheet of dura mater or covering that covers the cerebellum. Supratentorial is above the tentorium of the cerebellum and infratentorial is beneath the tentorium of the cerebellum. For the purposes of coding, the supratentorial is the part of the brain above the cerebellum, and infratentorial is the part of the brain beneath the cerebellum.



CASE 12-1   12-1A Operative Report, Ventriculostomy


CASE 12-1


Dick is a patient in the intensive care unit of the hospital. He has an obstructive hydrocephalus as a result of an intracerebral hemorrhage. Report the services of Dr. Pleasant.



12-1A  Operative report, ventriculostomy


LOCATION: Inpatient, Hospital


PATIENT: Dick Dawn


ATTENDING PHYSICIAN: Timothy Pleasant, MD


SURGEON: Timothy Pleasant, MD


PREPROCEDURE DIAGNOSIS: Obstructive hydrocephalus, secondary to intracerebral hemorrhage


POSTPROCEDURE DIAGNOSIS: Obstructive hydrocephalus, secondary to intracerebral hemorrhage


PROCEDURE PERFORMED: Ventriculostomy


OPERATIVE NOTE: While in the intensive care unit, the patient was noted to be deteriorating neurologically and suffering from obstructive hydrocephalus. The right side of the scalp was shaved, prepped, and draped in the usual sterile manner. A small incision was made in the midpupillary line approximately 10 cm (centimeter) behind the supraorbital rim. The standard hole was then fashioned. The dura was then punctured, and a catheter was inserted uneventfully into the right lateral ventricle. Bloody CSF (cerebrospinal fluid) was immediately obtained and was noted to be under high pressure. It was then externalized through the subcutaneous tissue and through another wound. The original wound was then sutured, and a sterile dressing was applied. There were no operative complications.




Craniotomy


A craniotomy is the surgical removal of a section of bone and is referred to as a bone flap (Figure 12-3). Removal of the bone is done in preparation for an operative procedure of the brain. The removed bone is returned to the original site at the end of the procedure. If tissue or bone is removed and not returned to the original site, the procedure is a craniectomy. For example, when a blood clot is removed and the bone flap is replaced, that is a craniotomy. If, however, a portion of the brain was removed due to a disease or condition, the procedure is a craniectomy. The craniotomy or craniectomy is performed for conditions such as trauma, infection, tumor, and aneurysm.


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FIGURE 12–3 Craniotomy.

Codes 61510-61530 report the removal or treatment of brain tumor(s), abscess, or cyst in which a portion of the skull bone is removed, procedure performed, bone replaced, and the bone then stabilized in place (Figure 12-5).


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FIGURE 12–5 Cerebral hemisphere and tentorium.


If stealth is used during the procedure, it is reported in addition to the procedure with 61781 if the procedure is intradural and 61782 if the procedure is extradural. A full description of stealth is presented before Case 12-3.



Subdural hematoma


A subdural hematoma is a hemorrhage characterized by a collection of blood between the dura mater and the arachnoid membrane (Figure 12-4). A subdural hematoma is often a result of contusion, with the source of the bleeding being an artery or vein. If the hematoma ruptures the arachnoid membrane, the condition is termed subdural hygroma. Subdural hematomas caused by trauma (such as head injuries) are categorized according to the presentation after injury: hyperacute (less than 24 hours), acute (1-3 days), early subacute (3-7 days), late subacute (more than 7 days), or chronic (more than 3 weeks). Other causes of subdural hematoma are artery or vein abnormalities (arteriovenous malformation) as a result of shunting procedures or a lumbar puncture, neoplasm, hypertension, hemodialysis, intracranial operations, infections, or as a result of bleeding disorder (such as hemophilia).


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FIGURE 12–4 Subdural hematoma.


From the Trenchesimage


“A successful medical coder will use their knowledge and coding tools to ensure their practice is in compliance to prevent audits.”


JOLEAN



CASE 12-2   12-2A Operative Report, Osteoplastic Craniotomy


CASE 12-2


The following craniotomy is for the purpose of removal of a subdural hematoma.



12-2A  Operative report, osteoplastic craniotomy


LOCATION: Inpatient, Hospital


PATIENT: Larry Colter


ATTENDING PHYSICIAN: Timothy Pleasant, MD


SURGEON: Timothy Pleasant, MD


PREOPERATIVE DIAGNOSIS: Acute subdural hematoma, left side


POSTOPERATIVE DIAGNOSIS: Acute subdural hematoma, left side


PROCEDURE PERFORMED: Osteoplastic craniotomy


ANESTHESIA: General anesthesia


PROCEDURE: Under general anesthesia, the left head was prepped and draped in the usual manner after having been placed in Mayfield pins. Hemoclips and Dandy clips were utilized on the scalp edges. Part of the temporalis muscle was taken down. Two burr holes and a circumferential flap were made. The bone was elevated. The dura was incised in an inverted U-shaped fashion. We saw acute clot; probably 45-50 cc of clot was irrigated from the frontal, temporal, and posterior parietal areas (indicates supratentorial; see Figure 12-2). Having cleaned it out, there was no free bleeder that I saw. I placed a piece of Gelfoam on the brain and then began closure of the dura with 3-0 Vicryl; this was done. A little patch was necessary; we used temporalis fascia. We tacked up the dura, replaced the bone flap, and utilized Wurzburg plates and burr hole cover. Having secured this, we then closed the scalp with 2-0 Vicryl on the galea with surgical staples on the skin, with a Hemovac drain having been applied prior to closure.




Stealth surgery


Stealth surgery is computer-assisted surgery that produces three-dimensional images and uses infrared intraoperative guidance, which enables location of tumors of the brain and spinal cord with great accuracy. The technology is the same as that of the B22 Stealth Bomber. A CT of the patient’s brain is input into the stealth computer to use as a road map during surgery. The computer tracks the surgical instruments being used by the surgeon during the operation by means of an infrared sensor that is located over the operating table. The computer then translates these instrument movements into a three-dimensional image for the surgeon to view. There is a red x located on the screen indicating the location of the tumor or area of damage. The technology is accurate to within 1 mm and greatly decreases damage to the brain during these invasive procedures. When stealth technology is utilized during a procedure (and the technology is used with a wide variety of procedures, not just brain surgery), you report the use of the technology in addition to the primary procedure. This technology is referred to in the CPT manual as stereotaxis, which is the method used to precisely locate areas of the brain. There are two codes to report cranial sterotaxis, depending on if the procedure was intradural or extradural (61781/61782). There is one code to report spinal sterotaxis (61783). The code for sterotaxis is located in the CPT index under “Stereotaxis, Computer Assisted.”


Computer-assisted surgical navigational procedures for musculoskeletal procedures are reported with 20985.



CASE 12-3   12-3A Operative Report, Craniectomy 12-3B Pathology Report


CASE 12-3


The label of a procedure (such as, craniectomy or craniotomy) does not mean that the title is the exact procedure. The following procedure is the removal of a tumor and an intracranial clot by means of a craniectomy. Sometimes, the report title might state craniotomy when a craniectomy was performed. Only careful reading of the entire report will reveal the exact procedure and ensure accurate coding. See Figure 12-6 for location of ventricle.


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FIGURE 12–6 Ventricles of the brain.


12-3A  Operative report, craniectomy


LOCATION: Inpatient, Hospital


PATIENT: Erika Witt


ATTENDING PHYSICIAN: Timothy Pleasant, MD


SURGEON: Timothy Pleasant, MD


PREOPERATIVE DIAGNOSIS: Recurrent tumor, intracranial clot


POSTOPERATIVE DIAGNOSIS: Recurrent tumor, intracranial clot


PROCEDURE PERFORMED: Craniotomy, removal of tumor, and removal of intracranial clot


ANESTHESIA: General


PREOPERATIVE NOTE: This patient has been forewarned about her condition and that we are operating on a marginally reserve patient, that we do not know what the results will be but will certainly try to remove the tumor and the clot to improve the situation.


This case was done under Stealth protocol (reported separately). We utilized a localizer, and we were able to show that the tumor cavity was totally entered and the tumor and clot were removed.


PROCEDURE: Under general anesthesia, the patient was placed in Mayfield pins. The head was prepped and draped in the usual manner. An inverted U-shaped incision was made. The previous craniotomy was opened up, and the dura was incised. We got into the ventricle. We removed what looked like yellow tumor, which was necrotic tissue. We removed a large intracranial clot as well and cleaned out the ventricular area. There was tumor or clot in the temporal lobe as well as in the lateral ventricle. I could see the foramen of Monro. I could clean out the entire cavity. This wound was irrigated; on the raw surface a piece of Gelfoam was placed after coagulation was achieved. The dura was then closed with Duragen. The bone flap was replaced with 22 wires, and the scalp wound was then closed in layers with 3-0 Vicryl on the galea and surgical staples on the skin. A dressing was applied. The patient was discharged to the recovery area.


Pathology Report Later Indicated: See 12-3B.




12-3B  Pathology report


LOCATION: Inpatient, Hospital


PATIENT: Erika Witt


ATTENDING PHYSICIAN: Timothy Pleasant, MD


SURGEON: Timothy Pleasant, MD


PATHOLOGIST: Grey Lonewolf, MD


CLINICAL HISTORY: Recurrent meningioma with intracerebral hemorrhage


SPECIMEN RECEIVED: Meningioma


GROSS DESCRIPTION:


The specimen is labeled with the patient’s name and “meningioma” and consists predominantly of blood clot with a few fragments of gray-tan lobulated tissue, 1 and 5 cm (centimeter) in greatest dimension. Representative sections are submitted in 6 cassettes.


MICROSCOPIC DESCRIPTION:


Sections of brain show areas of reactive gliosis with associated focal fibrosis, hemosiderin-laden macrophages, and foamy macrophages. Areas of recent hemorrhage with blood clot and focal areas of necrosis are also seen. A neoplastic infiltrate is not identified.


DIAGNOSIS:


Brain, frontal cortex, excision: Benign brain tumor showing reactive gliosis with areas of fibrosis, foamy macrophages, and foci of necrosis and accompanying blood clot.




CASE 12-4   12-4A Operative Report, Craniotomy


CASE 12-4


The removal of this tumor is conducted through a bone flap.



12-4A  Operative report, craniotomy


LOCATION: Inpatient, Hospital


PATIENT: Arlene Samuels


ATTENDING PHYSICIAN: Timothy Pleasant, MD


SURGEON: Timothy Pleasant, MD


PREOPERATIVE DIAGNOSIS: Right temporal parietal frontal brain tumor


POSTOPERATIVE DIAGNOSIS: Glioblastoma multiforme


PROCEDURE PERFORMED: Osteoplastic craniotomy with removal of tumor in temporal lobe, frontal lobe, and middle cerebral artery complex (contiguous [adjoining] sites).


ANESTHESIA: General


PROCEDURE: Under general anesthesia, the patient’s head was prepped and draped in the usual manner. A question mark incision was made in the front of the ear up to the frontal area. The skin flap was turned down. The temporalis muscle was incised. We then did an osteoplastic craniotomy with burr holes and craniotome. The flap was turned. The dura was incised. We then made an incision into the superior temporal lobe. The plan was to resect the temporal lobe to get into the tumor and stay away from the middle cerebral complex and also to decompress her on the frontal lobe as well since the tumor was going into the frontal lobe. I got into the tumor and sent specimen for biopsy and then began the gradual dissection. I encountered some bleeding, probably from middle cerebral artery branches. I had to take a few with silver clips, perhaps two to three. Otherwise, we left the sylvian vein intact and decompressed the area (decompression is bundled into tumor removal). We got into the tumor cavity and took as much visual tumor as we could. The bed was then dried. I irrigated the wound well. I placed a piece of Gelfoam over the raw surface of the brain and began closure of the dura with 3-0 Vicryl. The bone flap was replaced with two straight four-holed Wurzburg plates. Hemovac was placed, and the scalp was closed in layers utilizing 3-0 Vicryl on the galea with surgical staples on the skin. Dressing was applied. The patient was discharged to PAR (postanesthesia recovery).


Pathology Report Later Indicated: Glioblastoma multiforme




CASE 12-5   12-5A Operative Report, Pterygocraniotomy and Cranioplasty


CASE 12-5


An operating microscope is used in this procedure and is reported separately. Simple aneurysms are any that are 15 millimeters or less.



12-5A  Operative report, pterygocraniotomy and cranioplasty


LOCATION: Inpatient, Hospital


PATIENT: Brett Richards


ATTENDING PHYSICIAN: Timothy Pleasant, MD


SURGEON: Timothy Pleasant, MD


PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage secondary to right posterior communicating artery aneurysm


POSTOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage secondary to right posterior communicating artery aneurysm, 12 mm (millimeter)


PROCEDURE PERFORMED: Right pterygocraniotomy with microsurgical clipping of right posterior communicating artery aneurysm and cranioplasty


DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed under general endotracheal anesthesia. The right scalp (This indicates an intracranial approach as versus a cervical approach.) was then shaved, prepped, and draped in the usual sterile manner. A modified Souttar bicoronal incision was then outlined in the skin and subcutaneous tissue and was infiltrated with lidocaine with epinephrine. The skin was incised, and sharp dissection was carried through subcutaneous tissue. LeRoy-Raney clips were then applied to the skin edges and the galeacutaneous flap was elevated and reflected anteriorly. Temporalis muscle was then incised and reflected anteriorly, and a free bone flap was fashioned using a Midas burr. A generous craniectomy was carried out on the squamous portion of the temporal bone and the lateral sphenoid wing. Twenty-five grams of mannitol had been given prior to skin incision, and dura was noted to be moderately tense. A horseshoe-shaped dural flap was then fashion based inferiorly. Great care was taken to preserve the Sylvian vein. Only a small amount of cerebral edema was noted at this point. The anterior inferior aspect of the Sylvian fissure was then split, and the CSF (cerebrospinal fluid) was released. This portion of the procedure was somewhat tedious and allowed for brain retraction. The right olfactory nerve was then visualized and protected. The optic nerve was then identified as well as the proximal portion of the intracranial carotid artery. Fixed retractors were then placed, and the remainder of the procedure was carried out using microsurgical technique. The carotid cistern was opened using an arachnoid knife. The proximal portion of the intracranial carotid was then dissected free with thickened hemorrhagic arachnoid. Great care was exercised to minimize retraction on the temporal lobe. An aneurysm was noted in the proximal third of the intracranial and carotid artery immediately proximal to the bifurcation. (This indicates the intracranial aneurysm was in the carotid circulation.) Carefully dissecting the neck of the aneurysm revealed the origin of the anterior choroidal artery immediately distal to the neck. The dome of the aneurysm appeared to be immersed in scar and was largely immobile. After adequately dissecting the neck (This “neck” is the neck of the aneurysm, not the patient’s neck.) and allowing for passage of microdissectors along the tract of the clip, the straight clip was selected. Clipping of the aneurysm then proceeded uneventfully. Post clipping, the internal carotid artery was noted to be widely patent, and the anterior choroidal artery was also visualized and noted to be unaffected by the aneurysm clip. Hemostasis was then ensured. The exposed brain was lined with a single layer of Surgicel. The area was generously irrigated with a body-temperature saline. The dura was closed using a running silk suture. The dural tacking sutures were also applied. The bone cap was secured and a cranioplasty was carried out for the squamous portion of the temporal bone and the lateral sphenoid wing. Muscle flap of the temporalis muscle was then repaired using interrupted Vicryl sutures. The galea was closed using interrupted Vicryl sutures, and sutures were utilized for the skin. Steri-Strips and sterile dressing were applied to the wound. The patient tolerated the procedure well. The patient was noted to be moving all extremities in the operating room and was transferred to the recovery room in satisfactory condition.




CASE 12-6   12-6A Operative Report, Craniectomy


CASE 12-6



12-6A  Operative report, craniectomy


LOCATION: Inpatient, Hospital


PATIENT: Suzanne Tracy


ATTENDING PHYSICIAN: Timothy Pleasant, MD


SURGEON: Timothy Pleasant, MD


PREOPERATIVE DIAGNOSIS: Brain tumor


POSTOPERATIVE DIAGNOSIS: Brain tumor


PROCEDURE PERFORMED: Craniectomy and removal of temporal lobe tumor


ANESTHESIA: General


Stealth protocol was utilized in doing this tumor. It was utilized in localizing the tumor.


PROCEDURE: Under general anesthesia, the patient was placed in the supine position. The head was turned to the right. The head was prepped and draped. The phaser was utilized to localize the tumor and to place it into the Stealth machine. Having done this, we then prepped and draped the patient. We made a linear incision extending from the temporal pole, having localized the tumor on the surface of the skin with the pointer. I then incised the skin and incised the temporalis fascia and muscle. I divided it. I then proceeded to perform a burr hole and a small craniectomy over the right temporal lobe tip. This having been done, we then incised the dura. This tumor was attached to the dura, and I removed the tumor; it was the size of a walnut. This was undermined from the surrounding brain with patties. There was no bleeding. This came out very easily. We then utilized Duraplast to repair the dura. We were utilizing 4-0 Nurolon. The bone edges were packed with some beeswax, and the dural edges were cauterized. The Duraplast having been placed, I then put a piece of Gelfoam on this, and I approximated the temporalis muscle and temporalis fascia with 0 Vicryl. I utilized 2-0 Vicryl on the galea. Surgical staples on the skin. Tight dressing was applied, and the patient was discharged to recovery.


Pathology Report Later Indicated: Benign neoplasm, meninges




Cranioplasty


Cranioplasty is the repair of a cranial defect. The surgeon uses autograft (from the patient) bone that is shaped and grafted into the defect area. If the defect is larger or more complicated than the surgeon can repair by bone grafting, a prosthetic plate may be used. Sometimes the plate is used as the foundation on which the surgeon places surgical cement to fill in an area of defect. The CPT codes in the cranial repair category (62000-62148) are divided based on the type of repair and in some codes, the extent of the repair (see 62140 for defects up to 5 cm in diameter).



From the Trenchesimage


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JOLEAN



CASE 12-7   12-7A Operative Report, Cranioplasty


CASE 12-7



12-7A  Operative report, cranioplasty


LOCATION: Inpatient, Hospital


PATIENT: Sylvia Reagan


ATTENDING PHYSICIAN: Timothy Pleasant, MD


SURGEON: Timothy Pleasant, MD


PREOPERATIVE DIAGNOSIS: Cranial deformity


POSTOPERATIVE DIAGNOSIS: Cranial deformity


PROCEDURE PERFORMED: Cranioplasty


PREOPERATIVE NOTE: This is a patient who has had a cranial defect because she had a bone removed. She was in cerebral swelling post aneurysm clipping and she survived. Now she is set up to have repair of the 10-cm (centimeter) cranial defect. An expander had been placed in this defect before.


PROCEDURE: The patient’s head was prepped and draped in the usual manner. An incision was made in the skin. The expander was removed. There was a plate in there. We were able to use this as a base to pour the methylmethacrylate cement. This was fashioned over the steel mesh. Afterward, this was formed to fill the defect out. We utilized the burr to shape it to the defect. We then closed the wound in one layer utilizing 2-0 Prolene on the scalp. A dressing was applied, and the patient was discharged to the PAR (postanesthesia recovery).




Shunts


A shunt is a passage from one area to another that diverts fluid from one area to another. There are many different types of shunts. A ventricular shunt is a catheter that is placed into the ventricle of the brain to drain cerebrospinal fluid (CSF) into the peritoneal cavity. Figure 12-7 illustrates a ventriculoperitoneal shunt. If the catheter becomes damaged or otherwise obstructed, the shunt is replaced. The diagnosis is a complication of a catheter device.


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FIGURE 12–7 Ventriculoperitoneal shunt.


CASE 12-8   12-8A Operative Report, Shunt Repair


CASE 12-8



12-8A  Operative report, shunt repair


This is a report of a shunt obstruction, which represents a diagnosis of a mechanical complication of a shunt, specifically a ventricular catheter device (T85.-/996.X).


LOCATION: Inpatient, Hospital


PATIENT: Dean Rob


ATTENDING PHYSICIAN: Timothy Pleasant, MD


SURGEON: Timothy Pleasant, MD


PREOPERATIVE DIAGNOSIS: Shunt obstruction


POSTOPERATIVE DIAGNOSIS: Fracture of shunt


PROCEDURE PERFORMED: Repair of shunt. Replacement of ventricular catheter and valve.


ANESTHESIA: General


Under general anesthesia, the patient’s right head was prepped and draped in the usual manner. The entire abdomen and neck were draped. We were planning to possibly replace the entire shunt. After incising over the head and the shunt in the right posterior parietal area, it was obvious what the problem was. I incised the skin, turned down the flap, and the ventricular end of shunt had fractured from the shunt valve. I removed the valve. I removed the ventricular end and replaced it with a Delta One valve and 6 cm (centimeter) of ventricular shunt tubing and connected it up to the peritoneal catheter. It flowed easily. We did not inspect the peritoneal end, hoping that this would do and solve the problem. The fluid flowed freely into the peritoneal cavity. What I think happened here was the child probably hit his head and fractured the tube.


PROCEDURE: After reconnecting the shunt, we then closed the galea with 2-0 Vicryl interrupted and 4-0 nylon sutures on the skin. A dressing was applied. The patient was discharged to the PAR (postanesthesia recovery).




Lumbar puncture


A lumbar puncture is also termed a spinal tap. This procedure obtains cerebrospinal fluid by means of a needle inserted into the subarachnoid space in the lumbar region, as illustrated in Figure 12-8. The patient is positioned so the space between the vertebrae is as wide as possible. Any interspace can be used for the procedure, but L5-S1 is the largest and is most often used as the site of withdrawal. The CSF fluid is used for diagnoses of various conditions. Commonly assessed are the appearance, protein, sugar, serology, cell count, and at times bacterial and fungal cultures of fluid.


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FIGURE 12–8 Lumbar puncture.


CASE 12-9   12-9A Operative Report, Lumbar Puncture



12-9A  Operative report, lumbar puncture


LOCATION: Inpatient, Hospital


PATIENT: Larry Swope


ATTENDING PHYSICIAN: Timothy Pleasant, MD


SURGEON: Timothy Pleasant, MD


INDICATION: Vascular headache


PROCEDURE PERFORMED: Diagnostic lumbar puncture


PROCEDURE: Following Betadine prep, local anesthetic was instilled in the L3-4 (third lumbar vertebra-fourth) interspace. A #20-gauge needle was then inserted in this interspace and advanced until it entered the subarachnoid space on the second pass. Opening pressure was 110 mm (millimeter) of water. Five centimeters of crystal-clear fluid was obtained and sent to the laboratory for routine diagnostic studies, including viral culture. The patient tolerated the procedure well. He was given instructions as to how to avoid post–lumbar tap headache.


Related posts:

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  4. Evaluation and management services

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May 17, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Nervous system

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