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Code This!

Scenario Week of May 07, 2014:
View Current Scenario

Assign the correct codes for the following scenario using CPT diagnosis codes:

PROCEDURES PERFORMED

  1. Cervical spinal cord stimulator permanent placement
  2. Revision of the previous lumbar internal generator

DIAGNOSES

  1. Cervical postlaminectomy syndrome
  2. Chronic pain

ANESTHESIA: Monitored anesthetic care

COMPLICATIONS: None

ESTIMATED BLOOD LOSS: 5 cc

FINDINGS: Appropriate stimulation patterns were obtained in postop holding. The patient received 2 g of Ancef prior to incision.

PROCEDURE IN DETAIL: The patient was identified in the preop holding area. She again consented for the procedure and demonstrated clear understanding of what we were going to do. She denied any recent cough, cold, fevers, or chills. The patient was advised that we were going to remove her current lPG and replace it with a new 4-lead system. This had all been discussed in the office, and no further changes were made today.

The patient was then transported to the operating room and placed on the OR table with assistance of the staff. Proper positioning was confirmed and then the patient was given adequate sedation to tolerate the procedure. The neck through the right gluteal area were then prepped and draped in the normal sterile fashion. C-arm was utilized to identify the T3-T4 interspace and the area over the midline was anesthetized with approximately 15 mL of a half and half mixture of 1% lidocaine with epi and 0.5% Marcaine. The skin over the midline was then incised, and electrocautery was used to dissect down to the fascial plane.

Hemostasis was obtained. We then used a 14-gauge Epimed Coude needle to access the T3-T4 interspace using a low oblique approach and loss of resistance to a combination of saline and air. Once the epidural space was accessed, a percutaneous spinal cord stimulator lead was introduced and was guided up to the right C2 vertebral body. This movement was observed under live fluoroscopy as well as intermittent AP and lateral still shots to ensure proper placement and location. The process was then repeated on the left, and once both leads were in place, the patient was allowed to awaken to ensure proper stimulation patterns. After initial testing, some slight modifications were made, and the patient then described complete coverage of her normal pain patterns.

The patient was then re-sedated, and the needles were removed ensuring no significant change of the lead placement. The leads were then secured to the fascia using the Boston Scientific Clik Lock anchors, again using frequent visualization under fluoroscopy to ensure no lead movement. The skin over the implanted generator was then anesthetized with 10 mL of the same solution as before as well as an area on the right of midline in the lumbar spine that was also anesthetized to allow for an extension to be placed. The old generator was then explanted and the new generator was hooked up. We reconfirmed appropriate impedances from the lumbar leads. Once this was confirmed, we tunneled from the mid-thoracic incision site to the lumbar incision site. We then connected extensions, tested impedances, and completed tunneling all the way down to the lPG location. Once the system was completely hooked up, it was tested for proper impedances, and after that was confirmed, the new lPG was placed into the existing pocket.

All incision sites were then copiously irrigated and suctioned and dried. They were then closed with a 2-0 Vicryl deep stitch. Again, hemostasis was ensured and then the skin was closed with staples. The dressing was a bacitracin ointment covered by 4 x 4s and a Tegaderm.

The patient was then transported to the recovery area, where she underwent further education and programming from Boston Scientific. Initial report is appropriate stimulation patterns. The patient will be seen in the clinic for followup in approximately 1 week and staples will be removed in 7 to 10 days.

Please assign the correct CPT codes for the procedure above.


ANSWERS

CPT Codes
63650 Percutaneous implantation of neurostimulator electrode array, epidural
63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling

Rationale
In the index of CPT 2014, Professional Edition, under the terms Spinal cord, implantation (or insertion), pulse generator (or receiver), the coder is directed to code 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling. Additionally, under the terms Spinal cord, implantation (or insertion), the subterm electrode directs the coder to see code 63650 Percutaneous implantation of neurostimulator electrode array, epidural. Per the section guidance under the subsection Neurostimulators (Spinal) preceding codes 63650–63688, these codes “describe the operative placement, revision, replacement, or removal of the spinal neurostimulator system components to provide spinal electrical stimulation” and further details that a neurostimulator system is comprised of an implanted neurostimulator, external controller, extension, and collection of contacts or electrodes. A number, typically four or more, electrodes provide the actual electrical stimulation in the epidural space. In the case of CPT code 63650, as a percutaneously placed neurostimulator system, the electrodes are on a catheter-like lead.

In the April 11:10 CPT Assistant, the following question was posted:

“May code 63650 be reported for both insertion of a temporary percutaneous electrode array and a permanent percutaneous electrode array?

AMA Response: “Yes. The use of code 63650, Percutaneous implantation of neurostimulator electrode array, epidural, is not altered when the implantation of the percutaneous epidural neurostimulator electrode is performed for the purpose of a ‘temporary’ trial or for ‘permanent’ neurostimulation. The difference between the two procedures is the attachment of the electrode array to an external stimulator unit for trial stimulation as opposed to connecting to an implanted pulse generator or receiver for permanent stimulation. Attachment to an external stimulator unit is considered inherent to the work represented by code 63650. Therefore, it is not appropriate to report code 63685, Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling.

“However, if the percutaneous electrode array is attached to an implanted spinal neurostimulator pulse generator or receiver, then code 63685 would be reported in addition to code 63650, for the insertion or replacement of the pulse generator or receiver. Code 63685 includes the creation of a subcutaneous pocket made to house the stimulator and tunneling of the electrodes to the pocket. The generator is then placed in the subcutaneous pocket, lead impedances are tested to verify proper connection, and the device is programmed to begin stimulation (code 95972).”

The codes are sequenced according to the highest relative value unit or RVU. This would indicate the higher priced procedure, CPT code 63650 has a work RVU of 7.15 and code 63685 has a work RVU of 5.19; therefore, when sequencing these codes on the claim form, report 63650 as the primary code and 63685 as the secondary code. The use of modifier 51 would be appropriate for the second procedure.

Diagnosis Codes
722.81 Postlaminectomy syndrome, cervical region
338.4 Chronic pain syndrome

Rationale
In the ICD-9-CM alphabetic index, under the terms Syndrome, postlaminectomy, the subterm cervical directs the coder to see code 722.81. Confirmation is made by reviewing the code in the tabular section as well. For chronic pain syndrome, the main term Syndrome is once again referenced, then the subterm pain, and the subterm chronic which directs the coder to see code 338.4. The main reason for the procedure was the postlaminectomy syndrome which was the reason for the patient’s chronic pain.

 
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