# Tunnelling Leads



## SUEV (Jul 23, 2013)

When installing pain pumps or neurostimulators, the Anesthesiologist will place the catheter or lead and have our General Surgeon do the securing and tunneling of the catheter or lead.  The Surgeon will then also create the pocket for the pump or generator then connect everything.  Would it be appropriate for the General Surgeon to bill 62350-62 or 63650-62 for the placements or is the work of securing and tunneling included with the implantation of the pump/generator?

Thanks,
Sue


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## dwaldman (Jul 26, 2013)

For CPT 63650, Medicare does not allow for co surgeons they have a payment indicator of zero. But the tunneling portion as seen below would be included in CPT 63685. But what you are describe does not sound like they are acting as co surgeons for the placement of the IPG. They also do not allow for assistant at surgery so the securing of the lead would not be able to separately be reimbursed for the general surgeon. 

http://www.cms.gov/apps/physician-fee-schedule/overview.aspx



From AMA CPT Assistant April 2011, they describe the work included in CPT 63685. The guidance for 95972 you see in the question was prior to the newer requirement for reporting this code.

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). (Refer to Question 3 for further information related to the use of code 95972.)


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## dwaldman (Jul 26, 2013)

When I was referring to securing, I was indicating the securing of the lead at the thoracic level if that is what he is also helping with, but then I thought about it. And thought maybe securing meant connecting to the IPG. CPT 63685 in regards to Medicare payment indicators for co surgeons and assistant at surgery are:

 2 - Assistant at surgery may be paid.  

1 - Co-surgeons could be paid, though supporting documentation is required to establish the medical necessity of two surgeons for the procedure. 

But I assume the physician who is placing the leads are reporting 63650 per lead placed. And the general surgeon is reporting 63685.


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## SUEV (Jul 29, 2013)

The securing is done at the thoracic level by the general surgeon once the anesthesiologist verifies the placement of the lead.  The dictation reads:
"Electrode lead was carefully guided using C-arm control the left of the midline with its tip at T8 upper endplate.  Excellent stimulatory parameters were obtained with 100% coverage of the patient's pain.  Lead will be secured, tunneled and connected to generator by co-surgeon Dr. ____."  The code that is being billed by the anesthesiologist is 63663 (which does allow co-surgery) as this was a revision.

Since the tunneling for pain pumps is included in the catheter (not the pump), I'm surprised they're including it in the generator and not the lead/array for the neurostimulators.   Thanks for the article-I appreciate your help!  Sue


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