# Peripheral Nerve Stimulator Trial Help



## Melissa Harris CPC (Mar 3, 2015)

Hello,

Can someone direct me in how to bill this?  Two leads were placed but then one was removed and another implanted.   

DESCRIPTION OF PROCEDURE: With written and informed consent obtained, risk and benefits were discussed including but not limited to infection, post dural headache, temporary weakness/numbness of the arms, bone, nerve, spine damage, bleeding in the spine if taking ASA, NSAIDS, or blood thinners which can cause damage to the the spinal cord which can result in paralysis or death.  Benefits are include pain relief.  An IV was placed in the  Left  Antecubital and 1gram of Vancomycin  was given in 250ml of Normal Saline.  Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse.  The patient was then brought into the operating room.  With monitors in place the patient was placed prone on the fluoroscopic operating room table.  The area of the patient's entire neck and back of the head was first scrubbed, then prepped with alcohol, followed by betadine and drapped in a sterile surgical fashion.  Strict sterile  technique was followed for this procedure.
The  C2 interspace was then visualized. Skin wheals were raised   Right  and Left of this region  using up to  5  of 1% Lidocaine.  Another 4-5mL was used to infiltrate subcutaneous tissue using a  25 guage, 1.5 inch needle.  Then a 3.5 inch   14  gauge thuohy epidural needle was passed through the skin wheals from a caudad to cephalad direction subcutaneously on both sides .  Once the space was entered, an 8 electrode spinal cord stimulator trial lead from  Boston Scientific , model # SC-2352-50E, Lot #  16191824 was advanced up to the mastoid process bilaterally.  Both AP and lateral views reveal that the 8 electrode lead were placed in the correct position.  At this point, under my direct supervision , the  Boston Scientific   representative began trial stimulation.  Once satisfactory, a second 8 electrode lead, using the same model # was passed through a new 14-gauge thouhy epidural needle and directed toward the correct position.  Utilizing fluoroscopic guidance the same technique was utilized .  Once both leads were in place and checked in an AP and lateral views, again under my direct supervision stimulation is begun.  Once this was deemed satisfactory, the needle and stylettes were removed from the patient, leaving the two 8 electrode leads in place. The leads were then fixed to the skin using a small plastic cuff over the exterior portion of the lead.  A 2-0 silk suture on a curved cutting needle was placed through the cuff to the skin.  Bacitracin ointment was applied to the puncture wounds and the whole system was held in place with benzoin and clear occlusive bandages. The patient was then brought to the recovery area in stable condition where once again stimulation was programmed under my direct supervision and with my input.  At this point, the patient had suboptimal stimulation, therefore she was brought back to the operating room table and a third 8 electrode lead, using the same model # was passed through a new 14-gauge thouhy epidural needle and directed toward the correct position.  Utilizing fluoroscopic guidance the same technique was utilized .  Once all leads were in place and checked in an AP and lateral views, again under my direct supervision stimulation is begun. Once this was deemed satisfactory, the needle and stylettes were removed from the patient, leaving eventually two 8 electrode leads in place, which gave the best stimulation for the patient, removing the third electrode after intraoperative testing. The leads were then fixed to the skin using a small plastic cuff over the exterior portion of the lead.  A 2-0 silk suture on a curved cutting needle was placed through the cuff to the skin.  Bacitracin ointment was applied to the puncture wounds and the whole system was held in place with benzoin and clear occlusive bandages. The patient was given instructions to follow-up in the following week for stimulator removal and/or any problems that might arise.  

Any help is greatly appreciated

Melissa Harris, CPC


----------



## dwaldman (Mar 4, 2015)

0282T  
Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period  

_________________________________________
There was not a specific peripheral nerve that is being described in the operative report as the lead being placed over or near, the report states:

".....was advanced up to the mastoid process bilaterally."

I didn't know if this procedure represented peripheral subcutaneous field stimulation or if a specific peripheral was being targeted (again not mentioned in operative report.

I would query the physician to find out if like the example below which this procedure represents:

"Peipheral nerve stimulation PNS is for identifable nerve (such as sciatic nerve for patient with foot pain or occipital nerve for occiptial neuraglia) whereas peripheral nerve field stimulation involves subcutaneous placement of electical leads over generalized area of pain. "


----------



## dwaldman (Mar 4, 2015)

The below link which is an article addressing occipital nerve stimulation described at the mastoid process. So this appears to be the procedure that is being performed, but as seen below they describe peripheral sub. field stimulation and it would then be appropriate to report the category III code instead of PNS code CPT 64555. CPT 64555 has MUE (medically unlikely edit) of quantity 2 for Medicare or carriers that will only cover 2 leads.

I am not real familiar with PNS or PSFS procedures, so I answered with limited familiarity with exact coding after reading report that was provided.


www.karger.com/ProdukteDB/Katalogteile/isbn3_8055/_94/_88/PRNES24...

Classically, ?PNS is a procedure that targets a single nerve and attempts to produce a paresthesia that spreads along the territory innervated by the stimulated nerve? [2]. Recently, another clinical application of minimally invasive PNS was described [3] where significant open dissection near the peripheral nerve is avoided and near nerve electrode placement achieved. Subsequently in use now are two types of PNS: one minimally invasive approach using cylindrical leads and imaging guidance (ultrasound or CT), and classical nerve dissection where the nerve is exposed and lead placed directly to the nerve stimulated. Peripheral nerve field stimulation (PNfS) is a somewhat different technique where the goal is to ?produce a field of paresthesia within the peripheral distribution of pain by creating an electrical field around the activated bipoles? [2]. In PNfS, the leads are placed subcutaneously in the area of pain to stimulate the region of the affected nerves or the dermatomal distribution of these nerves (fig. 1, 2). Recently, initial successes of PNfS using cylindrical and paddle leads have been reported in a growing list of clinical settings, primarily in the head and cervical regions


----------



## Melissa Harris CPC (Mar 4, 2015)

Thank you so much!


----------

