Nervous System

1. DIAGNOSIS: Post dural puncture headache.

ANESTHESIA: Intravenous sedation

OPERATION: Epidural blood patch.

PROCEDURE: After satisfactory explanation of the risks and benefits of the procedure, patient was placed in the sitting position. His back was prepped with Betadine in a sterile fashion. A lidocaine skin wheal was made in approximately the L2-3 interspace. This site was approximately 2-3 cm above the superior aspect of a midline lumbar scar. A 17-gauge epidural needle was directed into the epidural space using loss-of-resistance-to-air technique. Negative aspiration for blood or cerebrospinal fluid was obtained. Twenty cc of blood was drawn sterilely from the right antecubital fossa. This was then injected slowly into the epidural space. Patient received 2 mg Versed during this procedure. He was taken to the recovery room in stable condition. He had good, though not complete resolution of his headache.

2. DIAGNOSIS: Degenerative arthritis of lumbosacral spine with bilateral lumbar facet syndrome.

OPERATION: 1. L3-4 facet injection, bilateral. 2. L4-5 facet injection, bilateral. 3. L5-S1 facet injection, bilateral. 4. Monitored intravenous Versed sedation.

PROCEDURE: The patient was taken to the block room. She was placed prone on the fluoroscopy table. She was monitored appropriately. She was administered Versed, a total of 4 mg IV. Her back was prepped and draped. Her O2 saturation remained greater than 90%. The C-arm was brought in and was rotated obliquely to the right. The facets at L3-4, L4-5, and L5-S1 on the right were visualized. After adequate local anesthesia, 22-gauge, 5-inch spinal needles were inserted.

One-half cc of contrast was injected into each joint verifying intra-articular needle placement. Depo-Medrol 10 mg plus 1 cc of 0.5% preservative-free Marcaine was injected into each joint. The needles were removed. I then rotated the C-arm obliquely to the left. The facets on the left side were visualized. After adequate local anesthesia, 22-gauge, 5-inch spinal needles were inserted into each of these joints. Correct needle placement was confirmed with fluoroscopy, and each joint was injected with 10 mg Depo-Medrol plus 1 cc of 0.5% preservative-free Marcaine. The patient was placed supine. Her back and leg pain were both much improved. She continued to have some pain in her upper back, but otherwise had no complaints.

3. DIAGNOSIS: Lumbar radicular pain syndrome.

NAME OF OPERATION: Selective root (nerve) sleeve injection on the left at L5-S1 with fluoroscopy.

PROCEDURE: The patient is taken to the block room, placed in the prone position on the x-ray table. Sterile prep and drape is applied. Local is with 3 cc of 1% plain lidocaine. Using fluoroscopic guidance, the neural foramen is obtained on the left at the L5-S1 level, confirmed with three views and the injection of contrast. The patient does note transient paresthesia on initial needle positioning, however, is not present on injection. Negative aspiration is followed with the injection of 0.5 cc of 1% plain lidocaine. This results in total resolution of the patient's pain complaint. She also notes some numbness in the left lower extremity which was in a similar location to that when it is experienced; however, this has not been continuously present. This is followed with repeat negative aspiration and the injection of 40 mg Depo-Medrol, 3 mg Celestone, 0.5 cc Wydase, and 0.5 cc of 0.5% ropivacaine. The needle is removed intact. There is no blood loss. There are no apparent complications. The patient is without complaints.

4. Diagnosis: Left cervical radiculopathy at C5, C6.

Operation: Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.

After informed consent was obtained from the patient, he was taken to the OR. After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted. At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position. The patient's posterior cervical area was then prepped and draped in the usual sterile fashion. At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine. A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated. After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken. This showed the spinous process to be at the C4 level. Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified. After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken. This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time. At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina. The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe. This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur. However, progress was limited because of thickness of the bone.Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area. After the bone had been thinned out, further bone was removed using the Kerrison rongeur. At this point the nerve root was visually inspected and observed to be decompressed. However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade. Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery. After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin. Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches. The subcutaneous layer was then reapproximated using 000 Dexon. The skin was reapproximated using a running 000 nylon. Sterile dressings were applied. The patient was then extubated in the OR and transferred to the Recovery room in stable condition.

5. Diagnosis: Bilateral carpal tunnel syndrome, left greater than right

Operation: Release of left carpal tunnel

After successful axillary block was placed, the patient's left arm was prepared and draped in the usual sterile manner. A linear incision was made in the second crease in the left hand, after a local had been injected, and this was taken down through that area, then curved slightly medially toward the hypothenar eminence, until approximately 1 cm proximal to the wrist crease. Once this was done, the incision was taken with a knife through the skin and subcutaneous tissue. Hemostasis was achieved with bipolar cautery. The ligament was then identified, and this was cut through with a scissors, starting proximally and working distally, until the whole ligament was freed up. The nerve was identified, and this was noted to be in continuity all the way through. The nerve was freed up, along the bands from this ligament. Once this was done and hemostasis was achieved, a few 2-0 Dexon stitches were placed in the subcutaneous tissue, and the skin was closed with interrupted 4-0 nylon.

6. Baby Smith was diagnosed with meningitis. His physician placed a needle through the fontanel at the suture line to obtain a spinal fluid sample on Monday. The needle was withdrawn and the area bandaged. The baby required another subdural tap bilaterally on Wednesday. How would you report Wednesday’s service?

7. Dr. Martin performed an excision at the middle cranial fossa for a vascular lesion. This procedure was completed in an intradural fashion with dural repair and graft. His partner, Dr. Sutter, performed an infratemporal approach with decompression of the auditory canal. How should Dr. Martin report her services?

8. After a snow skiing accident, Barry had a cervical laminoplasty to four vertebral segments. How should you report this procedure?

9. Phyllis fell down on the ice and fractured her leg. The fall also caused severe injury to the muscles and tore several nerves. Her physician completed suturing of two major peripheral nerves in her leg without transposition and shortened the bone. After the surgery she was seen by a physical therapist for ongoing treatment and gait training. How would you report the surgical procedure?

10. How is a neuroplasty procedure described in the CPT Professional Edition?

11. Maria had such severe headaches that she could find relief only with strong analgesics. Her condition of ------- was debilitating.

12. Paul was in coma after his high-speed car accident. His physicians were concerned that he had suffered a ------- as a result of the accident.

13. Dick went to the emergency department complaining of dizziness, nausea, and headache. The physician, suspecting increased ICP, prescribed corticosteroids, and Dick’s symptoms disappeared. They returned, however, when the steroids were discontinued. A/ an ------ (MRI of the brain, electroencephalogram, CSF analysis) revealed a large brain lesion. It was removed surgically and determined to be a/an ----------.

14. Dorothy felt weakness in her hand and numbness in her arm, and noticed blurred vision, all signs of --------. Her physician requested ------ to assess any damage to cerebral blood vessels and possible stroke.

15. To rule out bacterial ----, Dr. Phillips, a pediatrician, requested that a/an ----- be performed on the febrile (feverish) child.

16. Eight- year-old Barry reversed his letters and had difficulty learning to read and write words. His family physician diagnosed his problem as ------

17. After his head hit the steering wheel during a recent automobile accident, Clark noticed ------- on the left side of his body. A head CT scan revealed --------

18. For her 35^th birthday, Elizabeth’s husband threw her a surprise party. She was so startled by the crowd that she experienced a weakness of muscles and loss of consciousness. Friends placed her on her back in a horizontal position with her head low to improve blood flow to her brain. She soon recovered from her ------ episode.

19. Near his 65^th birthday, Edward began having difficulty remembering recent events. Over the next 5 years, he developed age-related ------- and was diagnosed with -------.

20. Disease of the brain -----

21. Part of the brain that controls muscular coordination and balance

22. Collection of the blood above the dura mater

23. Inflammation of the pia and arachnoid membranes

24. Condition of absence of a brain

25. Inflammation of the gray matter of the spinal cord

26. Pertaining to the membranes surrounding the brain and spinal cord

27. Hernia of the spinal cord and the meninges

28. Pertaining to the tenth cranial nerve

29. Collection of spinal nerves below the end of the spinal cord at the level of the second lumbar vertebra is called ------

30. Three protective membrane surrounding the brain and spinal cord -----

31. Fatty tissue that surrounds the axon of a nerve cell is called ------

32. Stromal tissue of the nervous system is composed of -----

33. ----- plays an important role in the blood brain barrier function of the nervous system.

34. ------ carry impulses from the CNS to organs that produce responses, such as muscles and glands.

35. The patient was taken to the procedure room and placed prone and the L4–L5 interspace was identified using fluoroscopy to determine the injection site. The patient was prepped in routine sterile fashion with Betadine and covered in sterile drape. 1% lidocaine was used to anesthetize the skin, subcutaneous tissue, and muscle. Once the proper anesthesia was obtained, a 3 inch, 20 gauge Tuohy needle was inserted and slowly advanced towards the L4-L5 interspace. Using a 6 cc glass syringe and the loss-of-resistance technique the epidural space was identified. After aspiration revealed no blood or cerebrospinal fluid return, the syringes were then changed and 80 mg/ml preservative-free Depo Medrol and 2 cc of 1% methylparaben free lidocaine were injected in slow incremental fashion. After aspiration, all needles were removed intact, the skin was cleaned and a Band-Aid was applied. Code this encounter.

36. A 42-year-old patient returns to the hospital neurology clinic for follow-up. He was checked three days prior to this visit where a lumbar puncture was done to find the etology of the patient’s headaches. The headaches have increased in intensity over the past three days. The neurologist examines the patient and finds a CSF leak from the lumbar puncture. A blood patch by epidural injection is performed to repair the leak. Code the services for today’s visit.

37. Postoperative Diagnosis: Carpal tunnel syndrome right wrist The patient was brought to the operating room and sedated by anesthesia. After sterile prepping and draping of the right hand, wrist and arm the patient’s area of incision was infiltrated with Xylocaine/Marcaine infiltration. After satisfactory anesthesia an Esmarch bandage was used to exsanguinate the right hand and wrist and used about the distal forearm as a tourniquet. A curvilinear incision was made on the palmar aspect of the right wrist. Dissection was carried out through the skin and subcutaneous tissue. Bleeding was controlled. The median nerve and it branches were identified, retracted, and protected at all times. The ligament was incised from proximal to distal. A thorough decompression was carried out. A neurolysis was carried out. The nerve was found to be flattened and ischemic underneath the transverse carpal ligament. The fascia was closed, the tourniquet was released. A dressing was applied and patient was transferred to recovery room. Code this procedure.

38. A 35-year-old man presents to the urgent care center with severe neck pain. The physician examines the patient and makes the diagnosis of cervical nerve impingement and injects an anesthetic agent into the cervical plexus using three injections. Select the procedure and diagnosis codes.

39. PROCEDURE: Bilateral lumbar medial branch block under fluoroscopy for the L3, L4, L5 medial branches for the L4-L5, L5-S/1 facets for diagnostic and therapeutic purposes. PROCEDURE: The patient was placed in the prone position on the fluoroscopy table and automated blood pressure cuff and pulse oximeter applied. The skin entry points for approaching the anatomic target points of the bilateral segmental medial branches or dorsal ramus of L3, L4, L5 were identified with a 22.5 degree from perpendicular lateral oblique fluoroscopy view and marked. Following thorough Chloraprep preparation of the skin and draping and 1% lidocaine infiltration of the skin entry points and subcutaneous tissues, a 22 gauge 6" spinal needle was placed under fluoroscopic guidance down on the target point for each respective segmental medial branch or dorsal ramus. At each point 1 mL consisting of 0.5% bupivacaine and Depo-Medrol was injected. A total of 80 mg of Depo-Medrol was divided between all six spots. Code the procedure(s).

40. The patient is a 64-year-old female who is undergoing a removal of a previously implanted Medtronic pain pump and catheter due to a possible infection. The back was incised; dissection was carried down to the previously placed catheter. There was evidence of infection with some fat necrosis in which cultures were taken. The intrathecal portion of the catheter was removed. Next the pump pocket was opened with evidence of seroma. The pump was dissected from the anterior fascia. A 7-mm Blake drain was placed in the pump pocket through a stab incision and secured to the skin with interrupted Prolene. The pump pocket was copiously irrigated with saline and closed in two layers. What are the CPT and ICD-9-CM codes for this procedure?

41. The patient is a 73-year-old gentleman who was noted to have progressive gait instability over the past several months. Magnetic resonance imaging demonstrated a ventriculomegaly. It was recommended that the patient proceed forward with right frontal ventriculoperitoneal shunt placement with Codman programmable valve. What is the correct code for this surgery?

42. What is the CPT code for the decompression of the median nerve found in the space in the wrist on the palmar side?

43. MRI reveals patient has cervical stenosis. It was determined he should undergo bilateral cervical laminectomy at C3 through C6 and fusion. The edges of the laminectomy were then cleaned up with a Kerrison and foraminotomies were done at C4, C5, and,,C6. The stenosis is central: a facetectomy is performed by using a burr. Nerve root canals were freed by additional resection of the facet, and compression of the spinal cord was relieved by removal of a tissue overgrowth around the foramen. Which CPT codes should be used for this procedure?

44. A craniectomy is being performed on a patient who has Chiari malformation. Once the posterior inferior scalp was removed a C-1 and a partial C-2 laminectomy was then performed. The right cerebellar tonsil was dissected free of the dorsal medulla and a gush of cerebrospinal fluid gave good decompression of the posterior fossa content. Which CPT code should be used?

45. Under fluoroscopic guidance an injection of a combination of steroid and analgesic agent is performed on T2-T3, T4-T5, T6-T7 and T8-T9 on the left side into the paravertebral facet joints. The procedure was performed for pain due to thoracic root lesions. What are the procedure codes?

46. DIAGNOSIS: Post dural puncture headache
ANESTHESIA: Intravenous sedation
OPERATION: Epidural blood patch.
PROCEDURE: After satisfactory explanation of the risks and benefits of the procedure, patient was placed in the sitting position. His back was prepped with Betadine in a sterile fashion. A lidocaine skin wheal was made in approximately the L2-3 interspace. This site was approximately 2-3 cm above the superior aspect of a midline lumbar scar. A 17-gauge epidural needle was directed into the epidural space using loss-of-resistance-to-air technique. Negative aspiration for blood or cerebrospinal fluid was obtained. Twenty cc of blood was drawn sterilely from the right antecubital fossa. This was then injected slowly into the epidural space. Patient received 2 mg Versed during this procedure. He was taken to the recovery room in stable condition. He had good, though not complete resolution of his headache.

47. The nervous system is composed of what two parts?

48. Which nerve is the largest nerve of the body?

49. What is not a region of the spinal cord nerve segments?

50. What is a vertebral segment?

51. hat part of the brain is affected when one has a astroke and is unable to speak or write?

52. Patient is a 59-year-old female woth failed back syndrome. She has undergone a recent test dose of intrathecal narcotics with good pain response. She has been brought to the operating room at this time for preparation and insertion of Medtronic programmable pain pump and intrathecal catheter. Select the procedure codes for this surgery.

53. College student comes into the ER with symptoms of headache and a high fever for the past two days. A lumbar puncture is performed and spinal fluid is sent to the lab to check for meningitis. Choose the correct procedure code.

54. A 35-year-old male has a left chronic subdural hematoma. He will be undergoing left burr hole evacuation of subdural hematoma. The correct procedure code for this surgery is:

55. A patient has severe spinal stenosis located between L3-L5 inferior to disc space. A laminectomy is performed on L4 along with a decompression of L3-L4. Choose the appropriate code for this procedure.

56. A 50-year-old with left internal carotid artery stenosis is having a left carotid thromboendarterectomy with electroencephalogram monitoring. The patient had electroencephalogram (EEG) leads placed on his head prior to the surgery. Throughout the whole time of the dissection, EEG patterns were symmetrical. Select the CPT code for this EEG monitoring.

57. A 45-year-old female has carpal tunnel syndrome. She is in surgery to have a neuroplasty performed on her left wrist. During the surgery the patient’s blood pressure starts dropping and the surgeon decides to stop the operation. How should the procedure code be reported?

58. A young child has been hit by a car. The neurosurgeon was called to the ER in which he examined the patient and finds the young child has a subdural hematoma. The surgeon makes the decision that the child needs to be taken to OR to drain the hematoma. Select the modifier appended to the Evaluation and Management service.

59. A 6-week-old baby had a cerebrospinal fluid shunt placed two days ago. The shunt is having a complication in which it is not draining the excess CSF. The baby is going back to the operating room for shunt removal and shunt replacement by the same surgeon who placed the original one. Choose the procedure code reported.

60. A patient is coming to the physician’s office for a follow up for a repaired damaged nerve to her finger. During the visit she tells the doctor she fell and hit her little toe this morning and now it is red and swollen and wants to make sure it is not broken. The physician examines the toe and reassures her that it is not fractured. The doctor also examines the finger, which is healing well with no infection. Select the E/M service for this visit.