# Need Assistance Coding SCS Removal



## celcano (Sep 5, 2017)

I have a case I have been pondering and I am unsure about the correct way to code this.  The patient had a permanent spinal cord stimulator placed on 06/16/17 .    There are note that the incisions healed well.  Then on 08/02/17, she called in (after a trip to Mexico) complaining of drainage from one of the incision sites.  She was seen that day and it appeared that the pocket site was infected.  We explanted the entire system the next day.  Here is part of the op note:
“Sharp and blunt dissection was utilized in both areas.  Full hemostasis was obtained with Bovie cautery. Up opening of the incision , yellow discharge came out. Culture was taken from the top incision ( upper thoracic incision).  The internal pulse generator and the extension wire were removed from the right side above the buttock area.  The anchoring device was disconnected from the epidural lead.  The epidural round lead was removed intact from the epidural space.  Both incisions were checked for hemostasis repeatedly.  Both incisions were irrigated with sterile normal saline mixed with bacitracin.  Then JP drain was placed in each of the incision. The drains were secure with 2.0 Silk.  The subcutaneous tissues were approximated using 2-0 Vicryl.  The skin was approximated using staples.  The incision was covered by gauze, telfa and tegaderm”

My first thought is that this is included in the removal of the generator and leads.  Then I started thinking…..this is outside of the original global period, there was more work performed that would have been performed just removing the system, we did place drains, etc.  So, my questions are:
1.	Would it be appropriate to bill for the incision and drainage in addition to the removal of the leads and generator?  
2.	If so, would we use 10060 (simple/single I&D) or 10180 (post-op wound infection) even though it is 6 weeks or so later?
3.	Or would it be appropriate to add a -22 modifier to the lead extraction code as it appears that a lead incision was the infected site? 
4.	I am completely off base and should just bill 63661 and 63688

Thank you for your thoughts on this.


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## dwaldman (Sep 9, 2017)

With the note that you provided, I would only report 63661 & 63688. The placement of drains considered inclusive to the global surgery package.

10180 or 10060 could be used if they were performed in a separate operative session. But the note does not support reporting them with the removal.

I don't believe I would report modifier 22 since removal for  complications is under the umbrella of removals.


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## celcano (Sep 11, 2017)

Thank you for your assistance.  I sometimes overthink things and do not want to leave money on the table.  This does make sense to me.  Thank you again.


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