# Stimulator Replacement



## gracec (Jun 26, 2014)

Hello all,

My provider did a replacement of a neurostimulator at an ASC and was wondering if the coding is correct?

Here's the report:

Postoperative Diagnoses:
1.	Lumbago.
2.	Peripheral nerve stimulator generator end-of-life failure.

Procedure:
1.	Peripheral nerve stimulator generator replacement.
2.	Generator pocket revision.
3.	Complex stimulator analysis.


Anesthesia:
Monitored anesthesia care.

Estimated Blood Loss:
Minimal.

Complications:
None.

Drains:
None.

Specimens:
None.

Indications:
complicated history of low back pain with short-term response to multiple interventions for which a peripheral nerve stimulator was previously placed. The stimulator has helped to reduce pain and reduced medication intake. Unfortunately, the generator has reached its end-of-life as per a recent interrogation of the device and presents today for replacement of the generator. The replacement generator is larger than the current generator and pocket revision will be necessary.

Procedure:
The risks and benefits of the procedure were again reviewed in detail and informed consent was obtained. The patient was brought into the operating room and placed in the prone position. All pressure points were properly padded and the patient was secured. Monitored anesthesia care was administered. Prophylactic Ancef was administered. The area over the existing generator was prepped with chlorhexidine prep and draped in the usual sterile fashion. Time out for safety was taken. The area surrounding the existing horizontal incision site was anesthetized with 5 mL of 1% lidocaine with epinephrine. An #11-blade scalpel was then used to enter the skin along the existing scar and was extended approximately 3 mm beyond the edges of the existing scar to accommodate the new generator. Bovie cautery was then used to extend the incision down towards the existing generator pocket and good hemostasis was obtained. Metzenbaum scissors were used to open the existing pocket and this generator was removed and the leads were detached. The replacement non-rechargeable generator was then attached to the leads and secured in place. The existing pocket was then extended using Bovie cautery and Metzenbaum scissors inferiorly and superiorly to accommodate the larger generator. The generator was placed within the pocket and the generator was then interrogated under sterile conditions and found to be working appropriately. The generator was then removed and the pocket was irrigated with antibiotic solution several times. The pocket was found to be hemostatic. The generator was then replaced into the pocket and the edges of the pocket were reapproximated using 2-0 Vicryl sutures in an interrupted fashion. The skin was then reapproximated using 3-0 Vicryl sutures in an interrupted fashion. The skin was then closed with 4-0 Monocryl in a subcuticular fashion with Dermabond. The skin edges were well approximated on conclusion. There was excellent hemostasis. The skin was then dressed with Steri-Strips, gauze and Tegaderm. The anesthesia was discontinued. Fluoroscopic images were obtained. The patient was turned supine and brought to the recovery room. With the patient awake and communicative, the stimulator was again interrogated and four programs created based on the patient?s response to its pain control. The patient reported excellent return of her pain control coverage. The patient will follow up in approximately one week for re-evaluation.
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I came up with 63685, 95972, 77003-TC, C1778, and C1820. Am I missing anything else? 

Thank you in advanced for your assistance!


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## dwaldman (Jun 26, 2014)

1. Fluoroscopy is inherent and inclusive stimulator types of procedure. It is not separately reportable. CPT 77003 would not be reported.

2. CPT 95972 has specific requirements. The main thing to consider is it is a time based code. So the physician would have to document the time spent. If under 31 minutes then 52 modifier is reported.

3. The C codes you provided do not appear correct. C1778 is for neurostimulator lead which there was not a new neurostimulator lead placed. 
C1820 is for rechargeable neurostimulator. The documentation states non-rechargeable. And the question arises is what type of carrier this where Medicare would bundle the payment into the CPT for the device. For non-medicare carrier should you be using L codes such as

 L8679* Implantable pulse generator, any type

C1778 Lead, neurostimulator (implantable) 
C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system 


4. If this is a stimulator for peripheral field stimulation then category III codes need to be reported for this service. With the diagnosis of 724.2 lumbago 996.2 mechanical complication of device. I think it is imperative that you confirm if this was for a specific peripheral nerve or this lead was placed near the spine to treat a field of pain as described below in AMA CPT Changes 2012. The difficulty arises because they do not just have a replacement of generator under the peripheral field stimulation codes thus could make difficult for a difficult coding scenario.

"This technique is different from peripheral nerve stimulation, in which specific peripheral nerves are targeted. In peripheral field stimulation, a field of pain is targeted rather than specific nerves."

Several new CPT codes were released by the AMA CPT Panel for reporting of peripheral field stimulation.  The codes are published as of July 1, 2011 and will become effective as of January 1, 2012.

0282T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period

0283T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; permanent, with implantation of a pulse generator

0284T Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed

0285T Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed

(Do not report 0282T-0285T in conjunction with 64550-64595, 77002, 77003, 95970-95973)  

AMA CPT Changes 2012



Four Category III codes have been established for reporting peripheral field stimulation. Peripheral field stimulation is a new technology for the treatment of chronic cervical, thoracic, or lumbar pain. Electrode leads are placed in subcutaneous tissue around the painful area, and electrical current is applied to create stimulation in the area, or field? of pain. This technique is different from peripheral nerve stimulation, in which specific peripheral nerves are targeted. In peripheral field stimulation, a field of pain is targeted rather than specific nerves. The elctrodes are placed in the skin either through an open or percutaneous approach. Imaging guidance is included, when performed.


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