# 63655 vs 63664 coding help



## 574coding (Oct 5, 2017)

We are looking for help with coding the revision code or initial placement code, in the case where a patient has epidural SCS Leads removed and paddle leads implanted. 

If they never had paddle leads before and the laminectomy is a new procedure done in order to place the paddle leads, would we use 63655?  

Would this be coded as 63664, 62350 or 63655, 62350?

Here is the report in question:

The patient was then placed prone onto the operating table.  The thoracic lumbar spine was then prepped and draped in the usual sterile fashion.  Prior scar tissues were noted over the upper thoracic, mid lumbar, left flank, right anterolateral flank from the pain pump.  The left flank was the battery for the stimulator.   Lidocaine with epinephrine was injected into all three junctions including the left spinal stimulator battery incision, midline lumbar incision area for the attachment of the leads, and in the upper thoracic 7-6 junction.  The C-Arm was brought in and imaging was taken to confirm the prior electrodes, which were up in the thoracic 3-5 junction and 4-5 junction.  Next a #10 blade was used to make an incision over the left lateral flank battery.  The fibrous capsule was incised using a Bovie.  The battery with the attachment leads were exposed.  The pocket was then irrigated with antibiotic solution.  Next a lumbar incision was made over the area of the battery lead attachment to the spinous process.   An incision was made with a #10 blade.  Within 5 mm of the skin, the lumbar pain pump tubing was identified and cut with the initial skin incision.  It was placed very superficially and therefore was cut during the initial skin opening for the lead wire detachment.  Both of these lead wires and the pain pump tubing were intertwined.  The pain pump tubing was then clamped.  The lead wires were then detached from the spinous process.  The leads were then pulled gently and both leads were removed without any incident.  

Next working superiorly, an incision was made over the thoracic 7 junction using a #10 blade.  Bovie was then used to maintain a periosteal dissection of the thoracic lamina.  Using a #2 curet, the ligamentum flavum was separated from the thoracic lamina.  Using a #2, 3 and 4 Kerrison, a left laminotomy was then done of thoracic 7.  The ligamentum flavum was removed in piecemeal fashion until the thecal sac was then viewed.  A Woodson was then used to separate some of the adhesions beneath the thoracic 7 lamina.  The paddle lead was then placed and was very difficult due to adhesions.  The lead was eventually migrating to the left.  Over 30 minutes were spent trying to maintain a midline lead placement but was very unsuccessful.  Therefore a left T6 laminotomy was done which assisted with the lysis of adhesions at the thoracic 6 junction.  Eventually, the lead was placed and guided to the thoracic 6 and maintained midline using various assisted devices.  Images were taken showing that the paddle lead was at the thoracic 6-7 junction.  This was ideal.  The leads were then tunneled through the skin into the battery pocket.  The leads were then attached to the battery and secured. Then the paddle lead and battery were interrogated and functioning.  Next, copious antibiotic impregnated solution was used to wash both the thoracic and left flank wounds.   The lead battery was secured next to the lamina around T8.  The excess lead wire was placed beneath the lead battery and placed in the pocket of the battery.  The left flank wound was then closed using 2-0 Vicryl sutures and then stapled.  The thoracic fascia was closed with 2-0 Vicryl sutures.  The skin was closed using staples.  

Next, a Tuohy needle was then used to enter the lumbar 2 dural space.  CSF was encountered.  Image guidance was used to introduce the catheter into the intradural space.  The pain pump tubing was then introduced to the cervical 7 thoracic 1 junction.  The guidewire was removed.  

The spinal needle was removed.  The intrathecal catheter was then secured using a  _____ fly wing.  Next, lateral tunneling of the tubing was done using a passer, ending in the right lateral flank.  The tubing was then passed through this and secured.  The lumbar incision was then closed using 0 Vicryl sutures and then stapled.  

The patient was then turned to a recumbent position/lateral recumbent position, where the anterior lateral abdomen was then prepped and draped in a sterile fashion.  Incision was made over the pain pump scar tissue after it was injected with lidocaine with epinephrine.  The pain pump was then removed.  A new tubing was attached.  The spinal tubing was attached to the pain pump tubing via its connecting device.  A needle was then placed into the pain pump and CSF was aspirated.  The pain pump was then placed back into its lateral abdominal pocket and then closed using 0 Vicryl sutures.  The skin was closed using staples.  The small 1 inch lateral incision was closed with 2-0 macro sutures and then stapled.  All wounds were dressed using the standard dressing.  The patient was then extubated and taken to the recovery room and able to move all extremities.  The lead placement was set.  The patient received adequate pain control with the stimulator.


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## dwaldman (Oct 7, 2017)

AMA CPT Assistant April 2011

Question 4: How would the removal of a permanent percutaneous catheter-type electrode with the insertion of a permanent paddle-type lead, placed via either a fresh
laminotomy or laminectomy at the same spinal level and connected to the existing implanted pulse generator,
be reported?

AMA Response: If removing a percutaneously placed catheter-type lead and replacing it with a paddle-type lead via a new laminotomy at the same level, code 63655, Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural, should be reported. The removal of the percutaneous electrode array is separately reported using code 63661......


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