# Revision w/ new Lami



## RebeccaWoodward* (Jun 14, 2010)

63664?  Or 63655/63685 since this was placed at a different level? Or something different?  Any and all opinions are welcomed-

PREOPERATIVE DIAGNOSIS: Spinal cord stimulator malfunction. 

POSTOPERATIVE DIAGNOSIS: Spinal cord stimulator malfunction with malfunction of lead and extension. 

SURGERY: Revision with placement of new laminotomy electrode in a new laminotomy with new extensions, which included removal and replacement of implantable pulse generator (IPG) unit, thus, revision of 
the entire system. 

The extension incision was opened. The lead tails were disconnected from the extensions. The lead tails were hooked to external testing wires. We tried interrogating the existing lead running up and down the electrodes, but the patient did not have adequate coverage of his back, and he wanted more back pain control than leg pain control. Thus, at this point, the patient was sedated more heavily, and I discussed with him placement 
of a new lead and extensions, as there was still one of the electrodes with higher impedances. Thus, I elected to place a new laminotomy electrode. 

His laminotomy incision from previous surgery was infiltrated with 1% plain lidocaine. This was opened sharply and dissection carried down to the wires. The wires were identified stress-relief coil. Subperiosteal 
dissection was performed along the left side. The laminotomy previously was identified. The wires were followed down into the laminotomy site. Prior to this, the IPG incision was opened sharply, and the IPG was 
removed from the IPG pocket and disconnected from the extensions. Thus, we could use Bovie during the case. I also had to remove it because I was going to replace the extensions as well. The extensions 
were removed. 

At this point, using very careful loupe magnification, headlight illumination, and microdissection, I was able to remove scar tissue from around the existing lead. Once this was performed, I was able to remove the lead. I then widened the laminotomy and tried replacing the lead but did not have ease of placement or adequate placement by fluoroscopy. The lead wanted to veer more laterally around the cord far laterally. Thus, this was removed, and I elected to go to the level above. Laminotomy was performed at the level above, which was T9. Laminotomy was performed and ligamentum flavum removed in piecemeal fashion. Hemostasis was obtained with bone wax, temporary use of Surgicel and Gelfoam, and also some FloSeal. 

With laminotomy performed, ligamentum flavum removed, the epidural fat removed, and dura identified, the hockey stick was placed with good placement. I then placed the lead and was able to place the lead again 
slightly toward the right and with basically one electrode above the T8 endplate. The patient was allowed to awaken from his anesthesia and communicate with us. We interrogated the lead placement, and he had 
good coverage in the leg and back, and thus, we elected to leave the lead in this place. 

At this point, the patient's anesthesia was deepened, and the system was tunneled. First, the lead tail was tunneled to the extension incision, and the new extension was placed. Extension was tunneled to the IPG 
pocket. IPG pocket was irrigated with antibiotic solution. The IPG unit itself was then reconnected to the new leads. The IPG was then replaced in the lead pocket and sutured in place. Stress-relief coil was placed behind the IPG, riding side, facing outward. This pocket was irrigated and then closed with 2-0 Biosyn suture and skin staples. Again, local was used throughout the case. This was 1% plain lidocaine. 

Next, the extension connections were placed in the subcutaneous layer at the next incision. This was irrigated out with antibiotic solution. Previously, the system had been torqued down to specification of the 
system with a self-limiting torque wrench. This incision was then irrigated with antibiotic solution and closed with 2-0 Biosyn and skin staples. 

Next, attention was turned to the laminotomy sites. The laminotomy sites with FloSeal for hemostasis, irrigation with antibiotic solution, some Surgicel placed along the existing lead at the new laminotomy site, DuraSeal placed, some further Surgicel placed, and wound irrigated and then closed with fascial layer approximated with 0 Vicryl sutures. The stress-relief coil was placed in the subcutaneous pocket. The final AP and lateral fluoroscopic images were obtained confirming placement. Subcutaneous layer closed with 2-0 Vicryl sutures and skin closed with skin staples.


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## RebeccaWoodward* (Jun 17, 2010)

I thought I would share what codes were eventually selected; in the event this scenario could benefit someone else in the future.

After a thoroughly discussing the case with the surgeon, we came up with 63664, 63685, and 63662 (63662-for the previous lead).  I also presented this operative note to another group and a highly respected consultant in the Pain Mgmt field also recommended 63664/63685.  Since 63662 was not suggested, I'm revisiting this code but *63664/63685* are the codes thus far.


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## dwaldman (Jun 17, 2010)

"Extension was tunneled to the IPG pocket. IPG pocket was irrigated with antibiotic solution. The IPG unit itself was then reconnected to the new leads. The IPG was then replaced in the lead pocket and sutured in place. Stress-relief coil was placed behind the IPG, riding side, facing outward."

Did you confirm that this was replacement of the IPG. With new IPG placed. I would let the physician know that the coding is based on whether a new IPG is placed and using the phrase "new IPG" helps distinguish that 63685 should versus if the IPG was taken out of the pocket and the same IPG was re-placed back in the pocket-- billing would then be 63688. The procedure note says "IPG was then reconnected to the new leads" that sounds like the IPG he removed was reconnected not that a new IPG was connected to the leads.


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## RebeccaWoodward* (Jun 17, 2010)

Original location: His laminotomy incision from previous surgery was infiltrated with 1% plain lidocaine. This was opened sharply and dissection carried down to the wires. The wires were identified stress-relief coil. Subperiosteal dissection was performed along the left side. The laminotomy previously was identified. The wires were followed down into the laminotomy site. Prior to this, the IPG incision was opened sharply, and *the IPG was removed from the IPG pocket and disconnected from the extensions*. Thus, we could use Bovie during the case. *I also had to remove it because I was going to replace the extensions as well. The extensions were removed. *

At this point, using very careful loupe magnification, headlight illumination, and microdissection, I was able to remove scar tissue from around the existing lead. Once this was performed, I was able to remove the lead. I then widened the laminotomy and tried replacing the lead but did not have ease of placement or adequate placement by fluoroscopy.* The lead wanted to veer more laterally around the cord far laterally. Thus, this was removed, and I elected to go to the level above.* Laminotomy was performed at the level above, which was T9.

New level: Laminotomy was performed and ligamentum flavum removed in piecemeal fashion. Hemostasis was obtained with bone wax, temporary use of Surgicel and Gelfoam, and also some FloSeal. 
With laminotomy performed, ligamentum flavum removed, the epidural fat removed, and dura identified, the hockey stick was placed with good placement. I then placed the lead and was able to place the lead again 
slightly toward the right and with basically one electrode above the T8 endplate. The patient was allowed to awaken from his anesthesia and communicate with us. We interrogated the lead placement, and he had 
good coverage in the leg and back, and thus, we elected to leave the lead in this place. 

At this point, the patient's anesthesia was deepened, and the system was tunneled. First, the lead tail was tunneled to the extension incision, and the new extension was placed. Extension was tunneled to the IPG 
pocket. IPG pocket was irrigated with antibiotic solution.* The IPG unit itself was then reconnected to the new leads.* *The IPG was then replaced in the lead pocket and sutured in place*. Stress-relief coil was placed behind the IPG, riding side, facing outward. This pocket was irrigated and then closed with 2-0 Biosyn suture and skin staples. Again, local was used throughout the case. This was 1% plain lidocaine. 

I did verify with the surgeon and the IPG was completely replaced.


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## dwaldman (Jun 17, 2010)

I am confused what they mean by "Do not report (63661-63662) for the same spinal level" under 63664. Does this mean if the previous paddle that was removed is at a separate spinal level as where the replacement is going to be anchored ,both codes can be reported with the 59 on 63662? I was reviewing some webinar notes and it was pointed out that in CCI 16.0 they changed 63688 and 63685 code pair to modifier allowed. So it seems you could bill 63685 63688-59, since they were two separate IPGs.


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## RebeccaWoodward* (Jun 18, 2010)

dwaldman said:


> I am confused what they mean by "Do not report (63661-63662) for the same spinal level" under 63664. Does this mean if the previous paddle that was removed is at a separate spinal level as where the replacement is going to be anchored ,both codes can be reported with the 59 on 63662? I was reviewing some webinar notes and it was pointed out that in CCI 16.0 they changed 63688 and 63685 code pair to modifier allowed. So it seems you could bill 63685 63688-59, since they were two separate IPGs.



I reviewed the Feb 2010 CPT Assistant and it only reiterates what is already stated in the CPT book..."same level". Therefore, I take this to mean that these codes can be reported together when a different level is involved; and in this case, it is. 
I can see why you added 63688. Here's my thought though...I'm selecting 63664 (plate-paddles) and 63685 (receiver) for the new level. I selected 63662 for the removal of the electrode plate/paddle for the previous location. I was thinking that 63685 would include the removal and replacement of the generator but maybe I need to look at this again. 

This was a tough one for me but the pieces are really starting to come together...


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