# STIM with one failed lead



## kseeg23 (Feb 24, 2014)

I'm not really sure how to code this procedure. The Dr said I should still bill for both leads, but I laughed when he told me that because I know that's not right but where the leads are billed per unit, I'm not sure how I show that the one lead was attempted but ultimately not placed. Here is the basic part of the procedure note:

The patient was taken to the operating room and placed in the prone position. Standard non-invasive monitors were then applied. Confirmation of the procedure to be performed was obtained from the patient. All surgical staff involved in the procedure wore standard sterile gown, hat, mask, and gloves. The skin overlying the operative field was prepped with duraprep and draped in a sterile fashion. A standard lap drape was placed over the operative field. Under flouroscopic guidance the entry point of T12-L1 was identified. The skin and underlying tissues were then anesthetized with 2% lidocaine using a 25 gauge needle. Under fluoroscopic guidance in the AP view, two 14 gauge tuohy needles were advanced to the epidural space using a loss of resistance technique. There were no parasthesias during needle placement. Through these needles, two stimulator trial leads, containing eight contacts each, were advanced, one was advanced to the target level T3 on the left. When attempting the second lead the epidural space would not allow for a second lead past T8. The second lead was then removed. Proper lead placement was confirmed in the lateral view showing the lead in the posterior epidural space. The lead was then connected to the trial generator and tested for proper coverage of the areas of pain. Once adequate coverage was obtained, the tuohy needles were removed. An incision was made to form a pocket for the generator over the left flank. The lead was then tunneled under the skin and connected to the generator. Testing showed proper conductance. The incision over the flank and midspine were then closed with sutures and covered with mastisol, steri-strips and protective gauze and tape. The patient tolerated the procedure well and was brought to the recovery area in awake and in hemodynamically stable condition.  
Radiation exposure time: 8 minutes and 11 seconds.   

It was done at a surgical center. My initial thought is to code it like this....

63650
63650-59-73
63685

I'm pretty sure that's incorrect so any help would be appreciated! Thanks


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## capricew (Feb 25, 2014)

the 73 modifier is only used for the facility billing the procedure.

for the physician you would bill the second lead with a -53 modifier to indicate that the attempt was made but discontinued.  The 53 modifier is not just for conditions that threaten the well being of the patient and a lot of people get confused by it.  You will also need to send in documentation with your claim so that the payer can see the extent of what was performed before that portion was discontinued.  Make sure you check the payers policy for this procedure as well before billing as they often have very particular rules on how to bill for these issues.

Good Luck!! 
Caprice Walder, CPC


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## dwaldman (Feb 25, 2014)

It was my understanding that when you have a completed procedure, you report the completed procedure codes. Procedures that were attempted at the same session  but not completely carried out are not reported. 

My understanding is the 53 modifier is for a complete procedure terminated. You list the main procedure that was attempted with the 53.

I don't have resources available to support this, but we don't bill on the physician side for an aborted lead placement when it is in conjunction with the a successful one.


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## kseeg23 (Feb 27, 2014)

Don't know what I'd do without all your help! Thank you so much!


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## capricew (Mar 4, 2014)

dwaldman said:


> It was my understanding that when you have a completed procedure, you report the completed procedure codes. Procedures that were attempted at the same session  but not completely carried out are not reported.
> 
> My understanding is the 53 modifier is for a complete procedure terminated. You list the main procedure that was attempted with the 53.
> 
> I don't have resources available to support this, but we don't bill on the physician side for an aborted lead placement when it is in conjunction with the a successful one.



Dwaldman,
I follow a lot of your posts, as you are very knowledgeable and i look to your guidance.  I guess this breaks down to how the rules are perceived.  I still respect the heck out of you though!


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