OP Note:
This was directly adjacent to the greater occipital artery and vein. The small medusa of veins had to be ligated to remove them from around the occipital nerve.

I was struck by the amount of inflammation in this area. This was more impressive than any other patient I had seen. The nerve was directly attached to the artery and it was quite challenging to separate the nerve from the artery itself. Once this was done with blunt dissection, the occipital artery was then resected along the course of the greater occipital nerve. I noted that there were distinct branches of the greater occipital nerve that the patient had identified preoperatively, one was 1 cm lateral to the most medial portion of the incision and the second one was 3 cm lateral to the most medial edge of the incision. The 3-cm branch was much larger. Both of these branches were followed back until they became a single greater occipital nerve.

I also noted in this wound a large lymph node that was directly compressing adjacent to the greater occipital nerve and this was removed using careful bipolar cautery and sent off as a specimen as a biopsy. This completes the biopsy of the deep cervical lymph node (38510).

Once the nerve had been identified, a vessel loop was placed around it and I followed it distally by releasing very tight remnants of the trapezius fascia over the nerve. This was followed until I was into the subcutaneous tissue. This was done over the first lateral branch and then the medial branch.

I then turned my attention proximally and followed the nerve beneath the trapezius muscle and these fibers were spread carefully in the undersurface of the trapezius was identified and a thick inferior trapezius fascia and fascia of the semispinalis capitis was identified. This was split distally and I identified where the occipital nerve coursed through the semispinalis capitis muscle. This was quite tight and there were several transverse fascial bands, which were clearly compressing the greater occipital nerve and I carefully using a lighter retractor, I was able to follow the nerve through the semispinalis capitis. All of these fascial bands were resected. A small area of muscle was removed using bipolar cautery. The nerve was seemed to take approximately 75 to 90-degree angle around one of these thick fascial bands and therefore this fascial band was completely removed and the muscle was divided. When I was completed, the nerve was free with no signs of compression from beneath the semispinalis capitis muscle through the trapezius muscle which a portion of it along with its fascia had to be removed and into the subcutaneous tissue. I then injected this incision with 0.25% Marcaine with epinephrine and closed with 4-0 Monocryl deep dermal and a 5-0 Prolene suture for the skin. A dressing was applied over this and the patient was flipped back into the supine position on the stretcher and extubated.

I have codes: 64716, 38510, and 64999 (resection of artery)
Physician has: 64716, 64722, 38510
I'm having trouble finding a code for the resection of the occipital artery, do I code it to 64999 or is it considered inclusive to 64716 because it was encountered while getting to the neurolysis of the greater occipital nerve???

Thanks in advance for all your help ,