Endocrine and Nervous System
Introduction
This chapter includes CPT, ICD-9-CM, and HCPCS Level II coding for the endocrine and nervous systems. Objectives for this chapter are:
- Review anatomical concepts to understand the endocrine and nervous systems
- Highlight relevant terminology
- Discuss application of most-frequently used CPT modifiers
- Provide an overview of ICD-9-CM and HCPCS Level II codes and coding guidelines as they apply to these systems
Anatomy and Medical Terminology
The Endocrine System
The endocrine system is comprised of ductless glands that produce various hormones and secrete them directly into the blood circulatory system. Hormones regulate many body functions, including growth and development, mood, metabolism, and tissue function.
The thyroid controls how quickly the body uses energy, makes proteins, and determines how sensitive the body will be to other hormones. This butterfly-shaped gland is composed of two wings, or lobes, on either side of the trachea, connected by an isthmus located over the trachea.
There are four parathyroid glands, embedded in the posterior surface of the thyroid gland, that maintain the body’s calcium level for proper functioning of the nervous and muscular system.
The thymus produces thymosin, which stimulates T-lymphocytes, or T cells, and produces and secretes hormones to control immune function. The gland is composed of two identical lobes, and usually shrinks after puberty. By adulthood, it is replaced by fat, but continue to produce T cells.
Each adrenal gland is comprised of two portions: the cortex (outer portion), and the medulla (inner portion). The cortex secretes glucocorticoids, mineral corticoids, and adrenal estrogen and progesterone. The medulla secretes epinephrine and norepinephrine (catecholamines). Pheochromocytomas are benign tumors of the chromaffin cells of the medulla, which produce extra catecholamines (fight or flight hormones). These tumors are sometimes extra-adrenal.
The pancreas performs both endocrine and exocrine (digestive) functions. The islets of Langerhans (pancreatic islets) of the pancreas produce the hormones insulin and glucagon that regulate blood glucose levels. As a digestive organ, the pancreas secretes digestive enzymes that flow into the pancreatic duct to the small intestine. CPT subheading Parathyroid, Thymus, Adrenal Glands, Pancreas, and Carotid Body includes the pancreas; however, there are no codes for the pancreas listed. Codes pertaining to the pancreas are listed in the Digestive System subsection.
Endocrine System
The carotid body, located at the bifurcation of the common carotid artery, contains some glandular tissue, and serves primarily as an “oxygen sensor” to help regulate breathing and blood pressure.
CPT groups the pituitary gland and pineal gland into the nervous system codes (61000-64999), due to the glands’ location within the brain. The pituitary gland has two lobes (anterior and posterior). This “master gland” regulates a wide variety of functions, from growth, to metabolism, to milk production and uterine contractions in pregnant woman. The pineal gland (also pineal body, epiphysis cerebri, or epiphysis) produces the hormone melatonin, which modulates wake/sleep patterns and seasonal functions, and serotonin that acts as a neurotransmitter and vasoconstrictor.
The testes and ovaries also secrete sex hormones as endocrine glands. CPT includes procedures for these organs in the Male Genital System (54000-55899) and the Female Genital System (56405-58999) sections.
The Nervous System
The nervous system is comprised of two parts:
- The brain and spinal cord (the central nervous system, or CNS)
- The remaining network of nerves running throughout the body (the peripheral nervous system, or PNS)
Nerves
Individual nerves come in a variety of sizes and specialized functions. At its most basic, however, a single nerve, or neuron, is comprised of a soma (or cell body, which contains the cell nucleus), several dendrites, and an axon.
Dendrites resemble tree branches, and increase the number of possible connections among nerve cells. Signals picked up by dendrites travel through the cell and continue along the axon, and are transmitted to the next cell. Axon terminals (synaptic bulbs) of a transmitting neuron and dendrites of a receiving neuron do not touch; they are separated by a small space, called a synapse. Across a synapses, minute electrical impulses are passed from one nerve to another via chemical messengers called neurotransmitters (such as serotonin). Any disruption of normal production or function of neurotransmitters may cause problems, including mood and attention disorders.
A nerve plexus is a network of intersecting nerves that combines spinal nerves serving the same body area. There are several plexuses in the body, including:
Cervical Plexus—Serves the head, neck, and shoulders
Brachial Plexus—Serves the chest, shoulders, arms, and hands
Lumbar Plexus—Serves the back, abdomen, groin, thighs, knees, and calves
Sacral Plexus—Serves the pelvis, buttocks, genitals, thighs, calves, and feet
Solar or Coccygeal Plexus—Serves internal organs
Because the lumbar and sacral plexus are interconnected, they sometimes are referred to as the lumbosacral plexus.
The Spinal Cord (and Spine)
The spinal cord has three main functions:
- To serve as a conduit for motor information that travels down the spinal cord (to the muscles)
- To serve as a conduit for sensory information that travels up the spinal cord (to the brain)
- To serve as a center for coordinating a number of reflexes
The spinal cord lies within the vertebral column, which protects it. Procedures of the spine and spinal column (62263-63746) may differentiate among vertebral segments and vertebral interspaces.
- A vertebral segment describes the basic constituent part into which the spine may be divided. It represents a single, complete vertebral bone with its associated articular processes and laminae.
- A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies that contains the intervertebral disc, and includes the nucleus pulposus, annulus fibrosus, and two cartilaginous endplates.
The main portion of the vertebra is the body (corpus). The vertebral foramen is the opening through which the spinal cord passes. The posterior projection of the vertebra is the spinous process. The projections on either side of the vertebra are the transvers processes. Between the spinous process and each transvers process are the laminae.
Facets joints—also known as paravertebral facet joints and/or zygapophyseal or “Z” joints—are located on the posterior spine on each side of the vertebra where it overlaps the neighboring vertebra. They are made up of two surfaces of the adjacent vertebrae separated by a thin layer of cartilage.
The brain is divided into distinct regions. The cerebrum contains the fontal, temporal, parietal, and occipital lobes. The frontal lobe is the front part of the brain. There are two temporal lobes located on either side of the brain. The parietal lobes lie just behind the frontal lobe and above the temporal lobes at the top of the brain. The occipital lobe is in the back of the brain.
The cerebellum is located at the “bottom” of the brain, below the occipital lobe. The brainstem is the low extension of the brain where it connects to the spinal cord. Most of the cranial nerves come from the brainstem. The ventricles of the brain are structures containing cerebrospinal fluid (CSF), which bathes and cushions the brain and spinal cord. The ventricles are continuous with the central canal of the spinal cord. The brain and spinal cord are covered by a series of tough membranes known as meninges. The meninges include the pia mater (inner), arachnoid mater (middle), and dura mater (outer).
http://www.unm.edu/~jimmy/spinal_nerves.jpg
ICD-9-CM Coding
The Endocrine System
ICD-9-CM codes related to the endocrine system are concentrated in chapter 3: Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders (240-279). Disorders of the individual glands are ordered by location (eg, disorders of the thyroid gland [240-246], disorders of parathyroid gland [252], diseases of thymus gland [254], etc.).
Use the Index to Diseases (Vol. 2) to find the disorder/disease, and confirm code selection in Tabular List (Vol.1). Be sure to heed all “includes” and “excludes” information, as well as required fourth- or fifth-digit specificity. Some codes may require an additional code be cited; for instance, instruction with 242.8x Thyrotoxicosis of other specified origin indicates, “Use additional E code to identify cause, if drug-induces.”
ICD-9-CM instructions in the Tabular List of chapter 3 specify: “All neoplasms, whether functionally active or not, are classified in chapter 2.” Codes in the Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders chapter “may be used to identify such functional activity associated with any neoplasm, or by ectopic endocrine tissue.” That is, the neoplasm should be report first, and any functional activity caused by the neoplasm should be reported as a secondary code.
Diabetes Mellitus
The ICD-9-CM Official Guidelines for Coding and Reporting provides extensive notes and instruction for coding diabetes and its manifestations. You should review these guidelines in full. The following summary identifies key points.
All diabetic codes fall into categories 249 and 250. The fourth digit indicates whether there are any complications or manifestations. If the patient has a documented manifestation, assign the diabetic code from categories 249-250, followed by the associated condition. For many diabetic codes there is a “use additional code” note for the manifestation specific for that diabetic code. Assign as many codes from categories 249 and 250 as necessary to identify all of the patient’s associated conditions.
The fifth digit in category 250 indicates the type of diabetes (type I or type II) and if it is controlled.
If the documentation doesn’t specify the type, or whether it is controlled or uncontrolled, assign code 250.00 Diabetes mellitus without mention of complication type II or unspecified type, not state as uncontrolled.
Secondary diabetes (category 249) identifies complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes always is caused by another condition or event, such as cystic fibrosis, neoplasm of pancreas, poisoning, etc. The fifth digit in category 249 indicates whether the secondary diabetes is controlled, unspecified “0,” or uncontrolled “1.”
The Nervous System
ICD-9-CM codes specific to the nervous system are listed primarily in chapter 6: Diseases of the Nervous System and Sense Organs (320-389). Use the Index to Diseases to find the disorder/disease, and confirm code selection by referring to the Tabular List. Be sure to heed all “includes” and “excludes” information, as well as required fourth- or fifth-digit specificity.
Meningitis
Meningitis is inflammation of the lining of the brain and/or the spinal cord, which also causes changes in the cerebrospinal fluid. When coding for meningitis, you must know the agent responsible (for example, pneumococcal, streptococcal, gram-negative anaerobes,
arbovirus, etc.). In some cases (eg, 321.3 Meningitis due to trypanosomiasis), you must code the underlying disease first (086.1 Trypanosomiasis with involvement of organ other than heart). For unspecified meningitis, report 322.9.
Encephalitis, Myelitis, and Encephalomyelitis
Encephalitis is swelling or inflammation of the brain. Myelitis is swelling/inflammation of the spinal cord. Encephalomyelitis is combined brain/spinal cord inflammation. When coding for these disorders, check ICD-9-CM notation as to whether you should first code the underlying disease, and whether additional E codes are necessary.
Organic Sleep Disorders
Organic sleep disorders, including organic insomnia (inability to sleep), hypersomnia (excessive sleep), sleep apnea (pauses in breathing during sleep), parasomnia (night terrors, sleepwalking, and related abnormal movement during sleep), and others, may be found in category 327.See subcategory 307.4 for sleep disorders not documented as organic.
Hereditary and Degenerative Diseases of the Central Nervous system
Codes 330-337 describe hereditary and degenerative diseases of the CNS. Diagnoses in this range include Alzheimer's disease (331.0), Reye's syndrome (331.81), Parkinson's disease (332.x), and abnormal movement disorders-such as blepharospasm (uncontrolled
winking, 333.81) and restless legs syndrome (333.94)-among others.
Follow ICD-9-CM instruction regarding the use of additional codes to identify associated conditions, or to report underlying diseases as primary. Watch also "excludes" notes.
Pain (not elsewhere classified)
The ICD-9-CM Official Guidelines for Coding and Reporting provide extensive notes and instruction for coding pain (category 338).The following summary identifies key points.
When reporting a pain diagnosis, identify as precisely as possible the location and/or source of the pain. If pain is the primary symptom and you know the location, the Index to Diseases will generally provide all the information you need.
If the patient has a documented, more-comprehensive diagnosis that causes the documented acute or chronic pain, but the documentation indicates the primary reason for the visit/service is management or control of the pain, report a diagnosis code from category 338 as the primary or first-listed ICD-9-CM code. Next, report the specific site of pain. The underlying cause is reported as an additional diagnosis, if known.
If the encounter is for any reason other than pain control or pain management, and a related differential diagnosis has not been established, assign the code for the specific site of pain first, followed by the appropriate code from category 338.
The official ICD-9-CM guidelines specify that you should not report a diagnosis from the 338 series "if the pain is not specified as acute or chronic ... except for post-thoracotomy pain, postoperative pain, or neoplasm related pain."
Note that chronic pain syndrome is not the same as chronic pain. Report chronic pain syndrome (338.4) only when the provider has documented that exact condition.
Know where to find the ICD-9-CM guidelines for pain.
They begin with 1.C.6.a.1-1.C.6.a.6.
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Other disorders of the Central Nervous system
Other disorders of the CNS are found among codes 340-349. Examples include multiple sclerosis (an autoimmune disease of the brain and spinal cord), some types of myelitis, and hemiplegia or hemiparesis (weakness on a single side of the body). Code selection is straightforward; be sure to abide ICD-9-CM instruction regarding the use of additional codes to identify associated conditions and/or cause. Watch also "excludes" and "includes" notes.
Migraine
Category 346 describes migraines. Per ICD-9-CM instruction, migraine does not include headache not otherwise specified (784.0) or various syndromes as described by 339.00-339.89. For each code in the 346.xx set, you must include a fifth digit to indicate the presence of status migrainosus:
0- Without mention of intractable migraine without mention of status migrainosus
1-With intractable migraine, so stated, without mention of status migrainosus
2- Without mention of intractable migraine with status migrainosus
3-With intractable migraine, so stated, with status migrainosus
Status migrainosus is an unrelenting, debilitating headache of severe intensity lasting more than 72 hours with less than an hour of pain-free period. The fifth digits also specify whether a migraine is "tractable" or "intractable." An intractable migraine is sustained and continual and does not respond to normal treatment.
A persistent migraine may occur with (346.6x) or without (346.5x) cerebral infarction. Migraine related to menstruation is reported to 346.4x.
Disorders of the Peripheral Nervous System
Disorders of the PNS are found in code sets 350-359. Examples include trigeminal nerve disorders (pain resulting in disorder of the nerve connecting part of the face to the brain), lesions of the nerve roots and plexus, nerve inflammation (neuritis-the most prominent of these is carpel tunnel syndrome, 354.0), and hereditary and idiopathic peripheral nerve disease (neuropathy).
Neoplasms
Neoplasms may occur throughout the endocrine and nervous systems. Selecting a neoplasm diagnosis is the same as for any other system. Go to the ICD-9-CM Index to Diseases, and look up the main term that describes the neoplasm type. Don't skip to the Neoplasm Table: Although the Index to Diseases directs you to the Neoplasm Table, checking the index is not a wasted step. You won't find all the codes you need in the Neoplasm Table. ICD-9-CM lists certain conditions only in the Index to Diseases; in other cases, using the Index saves time and reduces confusion.
If the Index to Diseases doesn't provide the information you need, consult the Neoplasm Table.
CPT® Coding
CPT codes relevant to the endocrine and nervous system will come primarily from the 60000 series, with some additional services in the 90000 series.
The Endocrine System
The Thyroid Gland
Procedures include incision and drainage, biopsy, and excision or aspiration of thyroid cyst. The majority of codes describe excision procedures, including total or partial removal of the thyroid that may include related procedures, such as neck dissection. Lobectomy describes removal of a single lobe of the thyroid, while isthmusectomy (for example, 60210-60225) describes
excision of the isthmus, or central portion, of the thyroid.
Parathyroid, Thymus, Adrenal Glands, Pancreas, and Carotid body
Procedures in this section describe primarily excisions of the parathyroid, thymus, adrenal glands, and carotid body. An adrenalectomy may be either open (60540—60545) or laparoscopic (60650).
Unlisted Procedure
Unlisted procedures of the endocrine system are reported using 60699. Use an unlisted procedure code only when no CPT code or category III code properly describes the procedure the provider performs. When filing a claim using an unlisted procedure code, submit a cover letter of explanation and full documentation of