Chapter 14: CPT Endocrine and Nervous System Practical Application Tips & FAQ

Case 1 – There is one CPT® code and one ICD-10-CM code reported. The documented procedure is a right thyroid lobectomy. Only the right thyroid lobe was removed making this a total unilateral lobectomy. In the CPT® Index look for Lobectomy/Thyroid Gland/Total. Read the code choices carefully. The Findings document a thyroid mass which is used for the diagnosis. A thyroid mass is considered a nodule. In the ICD-10-CM Alphabetic Index look for Nodule(s), nodular/thyroid (cold) (gland) (nontoxic).

Case 2 – There is one CPT® code and one ICD-10-CM code reported. The documented procedure is a near total thyroidectomy. A total right thyroid lobectomy was performed – and part of the left lobe making this a contralateral subtotal lobectomy. The isthmus was also removed. In the CPT® Index look for Thyroidectomy/partial for the code range. Read the descriptions of these codes to determine which code is the most appropriate for a total thyroidectomy with contralateral subtotal lobectomy and isthmusectomy. The documented diagnosis is papillary thyroid cancer. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/ thyroid (gland)/Malignant column.

Case 3 – There is one CPT® code and one ICD-10-CM code reported. The documented procedure is a subtotal thyroidectomy. There is also the removal of some lymph nodes due to malignant thyroid cancer. This isn’t considered a radical procedure. In the CPT® Index look for Thyroidectomy/Total/for Malignancy/Limited Neck Dissection. The documented diagnosis is papillary carcinoma of the left thyroid. The metastasis to the lymph nodes is not confirmed and is not coded. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/ thyroid (gland)/Malignant column.

Case 4 – There is one CPT® code and one ICD-10-CM code reported. The listed procedures are insertion of a left frontal ventriculo-peritoneal shunt and removal of right frontal external ventricular drain. There is no documentation to support the removal and the shunt insertion is coded. The creation of a ventricular peritoneal shunt was performed after a failed trial with an external shunt. In CPT® Index look for Shunt(s)/Brain/Creation for the code range. Code only for the primary surgeon. Review the codes in the range to locate the appropriate code. In the ICD-10-CM Alphabetic Index look for Hydrocephalus/post-traumatic NEC.

Case 5 – There is one CPT® code and one ICD-10-CM code reported. The documented procedure is a right-sided hemicraniectomy with duraplasty. In the CPT® Index, look for Craniectomy/Decompression for the code range. The indication for the surgery is an ischemic infarct. An ischemic infarct is a stroke caused by inadequate flow of blood to the brain. This patient had an infarct in the middle cerebral artery and then the infarct converted to a hemorrhage in the brain. The hemorrhage is the more definitive diagnosis. In the Alphabetic Index look up Hemorrhage, hemorrhagic/intracranial/subarachnoid (nontraumatic)/intracranial (cerebral) artery/middle cerebral. Select the 5th character for right middle cerebral artery.

Case 6 – There is one CPT® code and one ICD-10-CM code reported. The documented procedure is the replacement of a malfunctioning spinal neurostimulator pulse generator. In CPT® index look for Replacement/Neurostimulator/Spinal. The documented diagnosis is dorsal column stimulator battery malfunction. This is considered a complication of a mechanical device. In the ICD-10-CM Alphabetic Index look for Complication/electronic stimulator device/generator/breakdown.

Case 7 – There is one CPT® code and two ICD-10-CM codes reported. The documented procedure is a left craniotomy. The location of the craniotomy is important in code selection. A parietal craniotomy refers to the procedure performed above the occipital lobe and the tentorium (supratentorial). This is indication of an epidural hematoma. Knowing the location of the hematoma will help in code selection. In the CPT® Index look for Hematoma/Brain/Evacuation via Craniotomy. The diagnosis is an acute epidural hematoma. This is considered a traumatic hematoma because of the MVA. In the ICD-10-CM Alphabetic Index look for Hematoma/epidural (traumatic) and you are directed to see Injury, intracranial, epidural hemorrhage. Consider the 7th character carefully; there is no statement in the note that the patient lost consciousness. An External Cause code for the MVA is needed. In the ICD-10-CM Index to External Causes of Injuries look for Accident/motor vehicle NOS (traffic).

Case 8 – There are three CPT® codes and one ICD-10-CM code reported. The documented procedure is bilateral paravertebral facet joint injections with fluoroscopic guidance. The injections are performed in the right and left lumbar paravertebral facet joints for back pain and degenerative disc disease. In the CPT® Index look for Injection/Paravertebral Facet Joint/Nerve/with Image Guidance. This CPT® code range is divided into the region injected and how many levels are injected. Pay attention to the parenthetical statements regarding modifier use. The second and third codes are add-on codes and exempt from the multiple procedure modifier.
The patient’s diagnoses are low back pain and degeneration of a lumbar disc that involves the lumbar region. In the ICD-10-CM Alphabetic Index locate Degeneration/intervertebral disc/lumbar region. Refer to ICD-10-CM guideline Section 1.B.5 as you consider whether to code both low back pain and degeneration of the lumbosacral disc.

Case 9 – There is one CPT® code and one ICD-10-CM code reported. The documented procedure is a laminotomy, foraminotomy, decompression, bilateral decompression. A laminotomy is also known as a hemilaminectomy. These codes are divided by anatomical location, the numbers of interspaces involved and whether it is a re-exploration. In the CPT® Index look for Hemilaminectomy for the code range. Pay attention to the parenthetical statements regarding modifier use.

The documented diagnosis is spinal stenosis at L4-L5. There is also pain, numbness and tingling which are symptoms of spinal stenosis and are not coded. Look in the ICD-10-CM Alphabetic Index for Stenosis/spinal/lumbar region.

Case 10 – There is one CPT® and two ICD-10-CM codes reported. The documented procedure is a hemilaminectomy with L5-S1 foraminotomy. A laminotomy is also known as a hemilaminectomy. These codes are divided by anatomical location, the numbers of interspaces involved and whether it is a re-exploration. In the CPT® Index look for Hemilaminectomy for the code range. The documented diagnoses are radiculopathy and neural foraminal stenosis. In the ICD-10-CM Alphabetic Index look for Radiculopathy/lumbar region. For the 2nd diagnosis code, look for Stenosis/spinal/lumbosacral.

Chapter 14 FAQs
I am confused about when to add modifier 62 if it is a complicated procedure with two surgeons, help?
Many of the procedures in this section are complicated. There may be separate codes for the approach, the definitive procedure, and the repair. Rarely is modifier 62 needed for Surgery of Skull Base codes because if one surgeon performs the approach and another performs the definitive procedure, each reports a separate code.