# Revision of Percutaneous Placement of Three Epidral Leads



## NESmith (Jan 4, 2013)

Please advised if this is correct.
Percutaneous placement of three epidural leads for Spinal cord stimulation
Location: T8
Number of Total electrical contacts: Sixteen
Side: Midline
Levels: Needle entry at L1 electrodes pushed upwards the spine until they all tree reached T8.
A 16 ga Touhy needle is inserted in the skin and advanced using a very shallow angle of attack until it is perfectly midline and in the epidural space. This is confirmed with lateral fluoroscopy views.
The medtronic Octrode lead is then advanced and documented to be posterior to the thoracic foramina on lateral projections. the lead is advanced without any trouble or impediments all the way to the posterior epidural space by the arch of T8.
A second similar brand & make lead is advanced using the sae method. Thi slead is placed to the right of the first one  and this lead is a Quad eletrode.
A third similar brand & make lead is advanced using the same method. This lead is placed to the left of the first one and this lead is a Quad electrode.
Intraoperative testing done by connecting the leads to the Medtronic external programmer is done. The needle were removed and the electrodes were secured with dressing and anchoring tape devices.
63650
63650-7659
63650-7659

At 10:05 decision was made the leads are not in the right area of the spinal cord and she was taken back to the OR

Revison of Percutaneous placement of three Medtronic epidural leads for Spinal cord stimulation
Location: T9
Number of totla electrical contacts: sixteen
Side: Midline
Level: Needle entry L1 electrodes pushed upwards the spine until they all three reached T9
procedure repeated as above.
63650-7859
63650-787659
63650-787659
Thank You for your help in this matter. There is some disagreement as to the correct billing of these two procedures.


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## dwaldman (Jan 5, 2013)

The second procedure note was vague  to determine what transpired. Were the previously placed trial leads, taken out and had to be discarded and replaced with brand new leads? Or was there a way to manipulate them to desired spinal level without actually removing them completely.

If the leads had to be completely removed and the patient had to be re-sedated and separate encounter in OR, I can see where then replacing trial leads would be 63650-78 x 3 for  new insertion/replacement of trial leads.

But if the trials were not removed and just manipulated, this would be considered a revision of trial leads and there is not a code for this service, since as seen below CPT 63663 requires that revision or replacement to be of percutaneous permanent leads attached to an internal system. In this situation you would have to use unlisted CPT 64999 I believe.


__________________________________________________________________________
AMA CPT Assistant April 2011
Question 2: What CPT codes are reported when a temporary "percutaneous" electrode array is removed with the insertion of a permanent percutaneous electrode array and an implanted pulse generator or receiver at the same operative session? 

AMA Response: The revision of a percutaneously implanted system (code 63663) would only be performed after a permanent electrode array is in place and is later revised. As indicated in CPT Assistant August 2010, if during the trial period a level of pain relief has been achieved, a decision may be made to place a permanent electrode array. If the percutaneous trial electrode is removed and a new percutaneous permanent implant is placed, this constitutes placement of a new percutaneous implant, which would be connected to an implanted pulse generator. Procedurally, this would not be a revision. It would not be appropriate to report code 63663, Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed, because neither this type of electrode plate nor paddle was previously in place. Code 63663 would only be used if a previous permanent (internalized system) array of neurostimulator electrodes had been percutaneously placed, and is now being revised or replaced to improve efficacy. 

The work of removing a temporary percutaneous lead array is valued within the code for the "initial" placement (63650). Therefore, it would not be appropriate to report code 63661, Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed, when removing the percutaneous trial electrode. The placement of the permanent percutaneous neurostimulator electrode array would be reported using code 63650. Based on payer requirements, if performed during the postoperative period of the initial percutaneous electrode insertion (code 63650), it may be necessary to append CPT modifier 58, Staged or Related Procedure or Service by the Same Physician During the Postoperative Period.


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## NESmith (Feb 22, 2013)

Thank You as always dwaldman for your reply, but I have another question maybe you could help me with. We are being told by the Medtronic rep that we should not even be billing for the second procedure since the patient never left the facility. Is this correct and if it is please explain why?


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## dwaldman (Feb 23, 2013)

Below is from Medicare Internet Only Manual chapter 12----they recognized returning to the operating room on the same day as the initial procedure.

C.  Payment for Return Trips to the Operating Room for Treatment of Complications When a CPT code billed with modifier “-78” describes the services involving a return trip to the operating room to deal with complications, carriers pay the value of the intra- operative services of the code that describes the treatment of the complications.  

Refer to Field 18 of the MFSDB to determine the percentage of the global package for the intra- operative services.  The fee schedule amount (Field 34 or 35 of the MFSDB) is multiplied by this percentage and rounded to the nearest cent. When a procedure with a “000” global period is billed with a modifier “-78,” representing a return trip to the operating room to deal with complications, carriers pay the full value for the procedure, since these codes have no pre-, post-, or intra-operative values. 

When an unlisted procedure is billed because no code exists to describe the treatment for complications, carriers base payment on a maximum of 50 percent of the value of the intra-operative services originally performed.  If multiple surgeries were originally performed, carriers base payment on no more than 50 percent of the value of the intra- operative services of the surgery for which the complications occurred.  They multiply the fee schedule amount for the original surgery (Field 34 or 35) by the intra-operative percentage for the procedure (Field 18), and then multiply that figure by 50 percent to obtain the maximum payment amount. [.50 X (fee schedule amount x intra-operative percentage)].  Round to the nearest cent. If additional procedures are performed during the same operative session as the original surgery to treat complications which occurred during the original surgery, carriers pay the additional procedures as multiple surgeries.  Only surgeries that require a return to the operating room are paid under the complications rules.

 If the patient is returned to the operating room after the initial operative session, but on the same day as the original surgery for one or more additional procedures as a result of complications from the original surgery, the complications rules apply to each procedure required to treat the complications from the original surgery.  The multiple surgery rules would not also apply.

 If the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for multiple procedures that are required as a result of complications from the original surgery, the complications rules would apply.  The multiple surgery rules would also not apply. If the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for bilateral procedures that are required as a result of complications from the original surgery, the complication rules would apply.  The bilateral rules would not apply.


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