Vol. 16 Issue 14
Coding Nervous System Procedures
Case Study 1
Preoperative and Post-operative Diagnosis: Upper back pain.
Procedure Performed: Thoracic T5 epidural neurolysis.
Anesthesia: 2% Lidocaine.
Indications: The patient was evaluated in the emergency room. He had previous lumbar injections x 2 with improvement, but pain returned after a short period of time. Last time he was given a trigger point injection into the paraspinous muscles on the right with good recovery but still complains of midline back pain. He was informed of the risks and complications of having this block done, and agreed to proceed.
Operative Technique: The patient was placed in the sitting position. His back was prepped and draped in a sterile fashion and anesthetized with 2% Lidocaine.
The epidural needle advanced easily into the epidural space using a loss of resistance technique. At this point a total volume of 0.5 cc of 2% Lidocaine was injected without any problems. An epidural catheter was inserted and again 0.5 cc of Lidocaine was injected without any difficulty after aspiration. At this point a total volume of 1.75 cc of 6% Phenol was injected through the catheter with the patient in a 30% upright position.
The patient was allowed to remain in the emergency room for approximately a half hour at this point. He was re-evaluated, and his paraspinous muscle had relaxed. The pain was gone in his upper back and also in two small areas. He still has some right lower rib pain from previous fracture, but the predominant pain of the mid back was gone.
He was discharged in satisfactory condition. Will follow up with phone call in 2 days to evaluate therapy.
ICD-9-CM Code Assignments
Preoperative and Postoperative Diagnosis: Upper back pain.
724.5 Backache, unspecified
CPT Code Assignments, Rationale
In the documentation, you will see that the physician has listed an "epidural neurolysis" as the procedure performed. A coder's first instinct would be to look up the word neurolysis in the index. Under that term, you would find the following entries: Nerve 64704-4708 and then Internal 64727. The descriptions of the terms indicate that the codes describe neuroplasty and decompression, respectively. Neither of these is appropriate to the information under the operative technique section.
Another possibility, although incorrect, would be to look under the term Nerves, which is followed by injection, neurolytic agent É 64600-64681. Again, looking up the descriptors of these codes shows destruction by neurolytic agent.
The key to this procedure is that the physician performed an "epidural" injection. Note the following phrase at the start of the operative technique: "Epidural needle advanced easily into the epidural space" Check the index under Epidural and you will see that
the term Injection has the following codes listed: 6228162282, 6231062319, 6447964484. After checking the descriptors for these codes, you will see that code 62281, Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced solutions), with or without other therapeutic substance; epidural, cervical or thoracic, is the correct choice, and it should be assigned for both the facility and professional components.
Case Study 2
Preoperative and Postoperative Diagnosis: Laceration of the radial digital nerve of the left ring finger.
Procedure Performed: Microscopic repair of the lacerated radial digital nerve of the left ring finger.
Indications for Procedure: This is a 51-year-old female who injured her ring finger while working with a kitchen knife this past week. She was seen in the emergency room and felt to possibly have some tendon or nerve involvement per the patient's report and was referred to our clinic.
On examination she had loss of two-point discrimination over the radial aspect of her left ring finger. FDP and FDS tendons were fully functional and moving independently.
Operative Technique: The patient was taken to the operating room and placed under general anesthesia with endotracheal intubation. The left arm was placed on the hand table and prepped and draped in the usual sterile fashion with a tourniquet around the upper arm. Following exsanguinations of the arm, the tourniquet was inflated to 250 mm Hg. Following this, the patient's small (approximately 1-cm laceration over the radial aspect of her left ring finger) was extended both proximally and distally to allow visualization of underlying structures. The radial/digital nerve was identified and noted to be about 90% lacerated.
The wound was well irrigated, nerve ends were freshened and scar tissue was cleaned away from the ends. Following this, a #9-0 nylon stitch was used under the microscope to affect a nerve repair. Three stitches of #9-0 nylon were placed in the nerve. Following this, the wound was well irrigated again, and the wound was closed using #5-0 nylon in horizontal mattress fashion.
The patient tolerated the procedure well, and there were no complications. The wound was dressed with an Adaptic followed by fluff gauze, Kling wrap and cast padding. A dorsal splint holding the MPs at about 70 degrees of flexion with the finger IP joint neutral was applied.
ICD-9-CM Code Assignments
Preoperative and Postoperative Diagnosis:
Laceration of the radial digital nerve of the left ring finger.
955.6 Injury to peripheral nerve(s) of shoulder girdle and upper limb, digital nerve
E920.3 Accidents caused by cutting and piercing instruments or objectsknives, swords and daggers
CPT Code Assignments, Rationale
As indicated in the documentation, the surgeon performed a microscopic repair of the lacerated radial digital nerve of the left ring finger.
Because this procedure was performed on a nerve, you would check in the index under the main term Nerves, then Repair,
then Suture 6483164876. A review of the descriptors for these codes leads to the correct code, which is code 64831. Because the procedure was performed on the patient's left ring
finger, you will also assign modifier F3 (left hand, fourth digit) to the facility code.
Summary of CPT Codes
64831-F3 Suture of digital nerve, hand or foot; one nerve
64831 Suture of digital nerve, hand or foot; one nerve n
Monica Kiesecoms is a senior health care consultant with Medical Learning Inc. (MedLearn), St. Paul, MN.