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CPT Nervous System Guidelines

NERVOUS SYSTEM (61000 – 64999)

Structure & Function of the Nervous System

Central Nervous & Peripheral Nervous System

The central nervous system includes the brain and spinal cord. The peripheral nervous system contains 12 pairs of cranial nerves and 31 pairs of spinal nerves

The somatic nervous system coordinates body movements and receives external stimuli and is under conscious control.

The autonomic nervous system is divided into the sympathetic (responds to stress), parasympathetic (constricts pupils, slows heartbeat, dilates blood vessels, stimulates digestion), and enteric divisions (manages digestion) and is not under conscious control.

SKULL, MENINGES, AND BRAIN

Punctures, twists, or burr holes
The first two categories of codes are Injection, Drainage, or Aspiration (61000-61070) and Twist Drill, Burr Hole(s), or Trephine (61105-61253) that deal with conditions that may require holes or openings be made into the brain to relieve pressure, insertion of monitoring devices, placement of tubing, injection of contrast material, or to drain a hemorrhage.
A ventricular puncture (61020-61026) requires a puncture through the top portion of the skull, while a cisternal puncture (61050, 61055) is an approach at the base of the skull. To accomplish many of these procedures, twist or burr holes are made through the skull, which leaves the skull intact except for the small openings (holes).

Carniectomy/Craniotomy

Codes in the category Craniectomy or Craniotomy (61304-61576) describe procedures that deal with incision into the skull with possible removal of a portion of the skull to open the operative site to the surgeon. Assignment of these codes is based on the site and condition (e.g., evacuation of hematoma, supratentorial, subdural, 61312).

As in other subsections, many procedures are bundled into one craniectomy/craniotomy code. Only by careful attention to code description can you prevent unbundling surgical procedures and incorrectly report bundled components separately. Carefully review the descriptions of these codes before assigning a code.

When craniectomies are performed, it is not uncommon that additional grafting is required to repair the surgical defect caused by opening the skull. These grafting procedures are reported separately, in addition to the major surgical procedure.

Surgery of Skull Base

The skull base is the area at the base of the cranium where the lobes of the brain rest. When lesions are located within the skull base, it often takes the skill of several surgeons working together to perform surgery dealing with these conditions. The procedures located in the category Surgery of Skull Base (61580-61619) are very involved, taking many hours to complete. The procedures are divided on the approach procedure, the definitive procedure, and the reconstruction/repair procedure.

The approach procedure (61580-61598) is the method used to obtain exposure of the lesion (e.g., anterior cranial fossa, middle cranial fossa, posterior cranial fossa). The approach procedure is the anatomical location.

The definitive procedure (61600-61616) is what was done to the lesion (e.g., biopsy, excision, repair, resection). If one physician did both the approach and the definitive procedures, both would be reported.

For example, a neoplasm is excised at the base of the anterior cranial fossa, extradural using a craniofacial approach to the anterior skull base. This would be reported with 61600 for the procedure (definitive procedure, extradural excision of a neoplasm) and 61580 for the approach (approach procedure, craniofacial). Because two procedures (approach and definitive) were performed by the same surgeon, both codes would be reported for the physician— 61600 and 61580. The most resource-intensive procedure would be listed first without a modifier (definitive), and the lesser procedure (approach) would be listed second with modifier -51 appended.

Surgery of Skull Base

Code 61613 describes the obliteration (total destruction) of a carotid aneurysm, arteriovenous malformation, or carotid fistula and does not include the approach. Codes 61615 and 61616 report services at the base of the posterior cranial fossa and describe the resection or excision of extradural (outside the dura) or intradural (inside the dura) vascular or infectious lesions with or without graft. The approach for the resection is reported separately.

Codes in the Repair and/or Reconstruction of Surgical Defects of the Skull Base (61618, 61619) are performed to rebuild the area used for entry into the skull. This type of repair is the last step of reconstruction and is reported separately, only if the service was documented in the medical record as extensive.

At any point, one or more surgeons may be performing distinctly different portions of these complex procedures. When one surgeon performs the approach procedure, another surgeon performs the definitive procedure, and another surgeon performs the reconstruction/repair procedure, each surgeon’s services would be reported with the code for the specific procedure he or she individually performed. Again, if one surgeon performs more than one procedure (e.g., the approach procedure, the definitive procedure, and the reconstruction/repair procedure), each procedure is reported separately, adding modifier -51 to the secondary procedures.

For example, one surgeon performs the approach procedure (61580), definitive procedure (61600), and reconstruction/repair (61619). The services are reported as 61600 (the most resource intense), 61619-51, and 61580-51.

Aneurysm, Arteriovenous Malformation, or Vascular Disease

Aneurysms may develop within the brain and require surgical repair. An arteriovenous malformation is a condition in which the arteries and veins are not in the correct anatomic position, usually congenital.

Codes to indicate the definitive procedure or repair of these conditions are located in the category Surgery for Aneurysm, Arteriovenous Malformation, or Vascular Disease (61680-61711). These codes are divided on the basis of the approach and method of procedure.

Note:

An electroencephalograph (EEG) is used to monitor currents emanating from the brain and is usually utilized any time a procedure on the brain is performed. Report the EEG service separately with 95950.

Cerebrospinal fluid (CSF) shunts

A shunt can be considered a draining device that enables fluids to flow from one area to another.

A shunt is necessary when the body is not able to perform the drainage function on its own. In the case of cerebrospinal fluid shunts (62180-62258), the fluid is produced in the ventricles of the brain but does not drain properly and may continue to accumulate in the brain, building pressure and causing brain damage.

Drains or shunts are placed from the area of collection to a drainage area to keep the fluid level within a normal range. For instance, code 62223 describes the creation of a shunt from the ventricle to the peritoneal space (ventriculoperitoneal).

This means that the shunt originates in the ventricle of the brain and terminates in the peritoneum.

Codes in the CSF Shunt category describe all the various types of shunting procedures, including placement of shunting devices and subsequent repair, replacement, and removal. Shunt systems may also be placed to drain obstructed CSF from the spine.

SPINE & SPINAL CORD

The subheading Spine and Spinal Cord (62263-63746) includes codes for injections, laminectomies, excisions, repairs, and shunting.

The basic distinction among the codes in these ranges is the condition (such as a herniated intervertebral disc versus a neoplastic lesion of the spinal cord) as well as the approach (e.g., anterior, posterior, costovertebral).

SPINE & SPINAL CORD

Extracranial nerves, peripheral nerves, and autonomic nervous system

Nerves are our sensing devices, and they carry stimuli to and from all parts of the body. Some common procedures performed on nerves include injection, destruction, decompression, and suture/repair and are reported with codes from the Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System subheading (64400-64999).

The space around the nerves can be injected with anesthetic agents to cause a temporary loss of feeling (64400-64530). The code is assigned according to the type of nerve being injected.

Nerves may also be injected to cause destruction of the nerve and permanent loss of feeling in a specific area of the body (64600-64647, 64680-64681).

Extracranial nerves, peripheral nerves, and autonomic nervous system:

When reporting Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic codes in the 64400-64530 range, the coder must know the nerves, nerve groupings, and the interaction of the nerve with the body system(s). It is also important to identify the substance injected and the specific nerve the substance was injected into. Let’s take a closer look at the origin of these nerves and the interaction each has with the body system(s):

Trigeminal nerve (5th cranial) emerges from the lateral surface of the pons. The trigeminal nerve is a sensory nerve that supplies the face, teeth, mouth and nasal cavity, and a motor nerve that supplies the muscles of mastication (chewing).

Facial nerve (7th cranial) consists of the large motor root (supplies the muscles of facial expression) and a smaller root (nervus intermedius) that contains the sensory and parasympathetic fibers of the facial nerve.

Vagus nerve (10th cranial) has its origin in the lateral side of medulla oblongata and supplies sensory fibers to the ear, tongue, pharynx, and larynx and motor fibers to the pharynx, larynx, and esophagus.

Phrenic nerve affects the pleura, pericardium, diaphragm, peritoneum, and sympathetic plexuses. A plexus is a collection (aggregate) of nerves and ganglia.

Cervical plexus (posterior) is a plexus in the posterior cervical region that is formed by the dorsal rami of the first three or four cervical spinal nerves.

Axillary nerve originates from the brachial plexus at the axilla (armpit) level and is responsible for sensory information from the shoulder joint and the inferior region of the deltoid muscle.

Suprascapular nerve has its origin in the brachial plexus at the C5- C6 level that descends through suprascapular and spinoglenoid notches and supplies acromioclavicular and shoulder joints, and supraspinatus muscles.
Injection of anesthetic onto or around these nerves may be performed to block the pain sensation and provide relief from various pain, such as neck, lower back, myofascial pain syndrome, or cancer pain. There are many types of blocks, such as:
Brachial plexus block for upper extremity pain.
Celiac plexus (sympathetic nerve) block for pain in the abdomen.
Ilioinguinal block for pain from the pelvis area (groin, inguinal, or femoral).
Intercostal nerve block is for any of the 12 sets of nerves that travel between the spine and the rib cage.
Sympathetic blocks the nerves that are located along both sides of the spine and supplies the limbs and the abdomen.
Stellate ganglion block is performed for relief of sympathetic pain of the head or neck. The stellate ganglion is a group of nerves located on each side of the neck and help control blood vessels, sweat glands, and indirectly the temperature of the face, arms, and hands.
Paravertebral nerve block is performed for pain in the cervical, thoracic, or lumbar regions.
Somatic or sympathetic nerve injection is a rhizotomy. The agent injected may be chemical, thermal electrical, or radiofrequency.

Note:

Blocks are considered unilateral; modifier-50 should be used for bilateral procedures. When more than one level is involved, use the appropriate add-on code.

Blocks may also be performed when confirming a diagnosis.

For example, a lumbar-sacral paravertebral facet joint block (64490-64495) is one method utilized to document or confirm pain of the back. The patient with this condition usually has localized back pain aggravated by motion of the spine. During the procedure, a needle is placed in the facet joint or near the facet joint nerve under fluoroscopic guidance and a local anesthetic agent is injected. After control of the pain has been obtained, the patient is asked to perform activities that usually aggravate the pain. If the patient has decreased pain or absence of pain, the facet joint is identified as the source of the pain and appropriate treatment may be prescribed.

Neuroplasty is the decompression (freeing) of intact nerves (e.g., from scar tissue). If nerves receive excessive pressure from a source, such as scar tissue or displacement of intervertebral disc material, pain may occur.
Movement or freeing of nerves is reported with codes from the Neuroplasty (Exploration, Neurolysis, or Nerve Decompression) category (64702-64727).
Perhaps the most known neuroplasty procedure is a carpal tunnel release, reported with 64721, during which the median nerve and the transverse carpal ligament of the wrist are surgically released.
Nerves can also be removed or they can be repaired (sutured). The codes in the Neurorrhaphy (64831-64876) and the Neurorrhaphy with Nerve Graft (64885-64911) categories describe nerve repairs on the basis of the specific nerve being repaired.
This category also includes codes that describe grafting on the basis of the size of the graft.

CPT Nervous System Guidelines

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