Endocrine and Nervous Systems

1. Endocrine and Nervous Systems Lamon Willis

2. Endocrine

3. Glands Secretory Excretory Hormones Endocrine System - Anatomy

4. Glands include: Thyroid Parathyroid Adrenal (medulla, cortex) Pituitary (anterior, posterior) Thymus Pineal Pancreas Endocrine System - Anatomy

5. Thyroid Lobes Isthmus T3 – triiodothyronine T4 – tetraiodothyronine or thyroxin(e) Calcitonin Thyroid Gland

6. Thyroid hormone Iodine TSH – thyroid stimulating hormone or thyrotropin (pituitary) Goiter Calcitonin Thyroid Gland

7. Hyperthyroidism Graves’ disease Hypothyroidism Myxedema Cretinism Thyroid Gland

8. Parathyroid hormone (PTH) 4 small glands Calcium Hypocalcemia Hypercalcemia Parathyroid Glands

9. Fetus Puberty Involution Lymphocytes, T-lymphocytes or T cells Thymosins Thymus Gland

10. Adrenal or suprarenal Medulla epinephrine, norepinephrine pheochromocytoma Cortex zona: glomerulosa, fasciculata, reticularis glucocorticoids, mineralocorticoids, sex steroids Adrenal Gland

11. Steroid hormones Glucocorticoids – cortisol Mineralocorticoids – aldosterone Sex hormones – estrogen, androgen Addison’s disease Cushing’s syndrome Adrenal Cortex

12. Endocrine Insulin Glucagon Exocrine Digestive enzymes Pancreas

13. Anterior Pituitary Growth hormone, GH TSH FSH Prolactin ACTH MSH Hypothalamus controls hormone secretion Pituitary Gland (hypophysis) Posterior Pituitary • Oxytocin • ADH – vasopressin or antidiuretic hormone • diabetes insipidus

14. Located above the cerebellum Deep in the brain Melatonin Biorhythm Sleep-wake cycle Maturation Pineal Gland

15. Endocrine System Procedures 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 60252 Removal of thyroid 60260 Repeat thyroid surgery 60271 Removal of thyroid 60280 Remove thyroid duct lesion 60281 Remove thyroid duct lesion • Incision and drainage – one code: • 60000 • Excision: 60100-60281

16. Endocrine System Procedures • 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.

17. Endocrine System Procedures • 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 contra- lateral (opposite side) subtotal lobectomy is performed during a complete lobectomy, the service is reported with 60225.

18. Endocrine System Procedures • 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.

19. Nervous System

20. Neurons Cell body Dendrites Axons Myelin Synapses Nervous System

21. Neurotransmitters Glia, glial cells, neuroglia Astrocytes (astrocytoma) Dendrites Synapse Demyelination - MS Nervous System

22. Nerve plexus or plexi Cervical Lumbar Brachial Sacral Coccygeal Nervous System

23. Central Nervous System – CNS Brain Spinal cord Nervous System

24. Peripheral Nervous System Cranial nerves Spinal nerves Nervous System

25. Alzheimer’s disease Progressive Parkinson’s disease Dopamine Multiple sclerosis – MS Epilepsy Disorders

26. Cerebrum Corpus callosum Cerebellum Brainstem Midbrain Pons Medulla oblongata Brain

27. Cerebrum (cerebral cortex) Cerebral hemispheres Frontal Parietal Temporal occipital Basal ganglia Brain

28. Occipital lobe Cerebellum Brainstem Medulla Pons Brain

29. Ventricles Choroid plexus Cerebrospinal fluid - CSF Brain

30. Stroke Ischemic event Hemorrhagic stroke Aneurysm Transient Ischemic Attack -TIA Brain

31. Spinal nerves - motor and sensory fibers, dorsal and ventral roots Cervical – 8 Thoracic – 12 Lumbar – 5 Sacral – 5 Coccygeal - 1 Spinal Cord

32. Spinal nerves Interspace Disc Nucleus pulposus Annulus fibrosis Cartilage endplates Spinal Cord

33. Cranial Nerves I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens Peripheral Nervous System VII Facial VIII Vestibulocochlear IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal

34. 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 (I-IV)

35. Cranial nerve V - trigeminal nerve 3 branches sensory ophthalmic motor – mastication Trigeminal neuralgia, tic douloureux neurodynia Cranial Nerves (V)

36. 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 (VI-VIII)

37. 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 Cranial Nerves (IX-XII)

38. Femoral Common fibular Intercostal Median Musculocutaneous Radial Peripheral Nervous System (cont) • Saphenous • Sciatic • Subcostal • Tibial • Ulnar

39. Carpal tunnel syndrome Nerve entrapment Bell’s Palsy Mononeuritis Polyneuritis Peripheral Nervous System (cont)

40. 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. Nervous System Procedures

41. 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. Nervous System Procedures

42. 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.” Nervous System Procedures

43. “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.” Nervous System Procedures

44. 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: Approach Definitive Procedure Secondary Repair Nervous System Procedures

45. 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. Nervous System Procedures

46. 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. Nervous System Procedures

47. 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 Nervous System Procedures

48. 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. Nervous System Procedures

49. 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. Nervous System Procedures

50. 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. Nervous System Procedures