# Clarification Needed



## Melissa Harris CPC (Aug 20, 2014)

Hello,

My provider was a second surgeon in a placement of bifrontal and bioccipital peripheral nerve stimulator electrodes percutaneously with implantation of an IPG under fluoro.    It was coded as 63685 and 64555 x 4.  The insurance paid the 63685 but denied 64555 as non covered.  I was looking at the report (I did not code it originally) and am thinking it should have been billed 64575 instead of the 64555?  Can someone please review and advise what the codes should be??  


Operation:  Placement of bifrontal and bioccipital peripheral nerve stimulator electrodes percutaneously with implantatin of an IPG under fluoroscopy.

Preoperative and Postoperative Diagnosis:  Chronic Intractable headaches.  

The left leg was marked as the side of his IPG.  He was then brought to the operative theater where successful general endotracheal anesthesia was insituted.  compression stockings and pneumatic ompression boots were applied.  Sterile foley catheter was inserted.  His antibiotics were started.  He was then shaved below the level of the temporal line bilaterally and across the back and positioned in the left lateral decubitus position with an axillary low on the bean bagAll points of pressure were padded and secured.  We then marked an entry point for his right frontal percutaneous electrode then we marked another point just behind the ear above the mastoid for anchoring purposes and then a midline point at the inion.  We did a time out.

We then prepped the patient with a scrub of Betadine and then prepped with chloral prep and after waiting 3 minutes draped in the usual sterile fashion.  We infiltrated our different skin incitions with 1% lidocaine and Epinephrine.  We then made a small stab wound in the right frontal position just lateral to the corner of the eye and identified the fascia where we placed an #0 stitch in preparation for anchoring the wire.  The Dr. used a touhy needle to place a percutaneous supraorbital wire.  Fluoro was checke and then we placed a cuff around that wire and secured it down to the pericranium, opened a small pocket there and then tunneled from that pocket up to the eybrow incision and brought the wire back.  We then made or midline subovvipital incision , dissected down to the deep facia and again created a pocket there, which would accept various wires and we tunneled from that pocket to the retroauricular pocket and brought that single bifrontal wire back and then *Dr. A (my doctor)* placed a percutaneous 1 x 4 ANS St. Jude Medical wire along the nuchal line.  Once we were comfortable with this position fluoroscipally we placed the cuff over it and anchored it to the deep fascia and then rechecked our fluro.  We were happy with both wires.  All three incision were irrigated and closed.

We then broke down the table reposition the patient in the right lateral decubitus position again placing an axillary roll and making sure that all points of pressure were secured and then reprepped....   We then repeated the process of placing a left supraorbital percutaneous wire, placing a cuff over it and anchoring it to the fascia.  We then opened the retroauricular incision, dissected from there up to the eyebrow incision, brought the wire back and made a star retention loop and secured it and the tunneleed from the occipital incision forward, brough that wire back and then *Dr. A (my doc)* as he had placed the frontal wire, placed an occipital wire. We again anchored that with a cuff around the wire and a star retention loop.

A tthis point we then measured our wires and found that we were going to have to make relaxing intermediate incisions.  In the midline between the shoulder blades I made a roughly inch and a half incision, dissected down to the deep fascia and then we tunneled from the occipital incision to that incision and brought all four wires down . We placed a two-into-one connector connecting the bifrontal wires together. We check those connections, torqued them, checked them again and then secured them with their cuffs.  We then made another relaxing incision in the left flank, tunneled from the midline thoracic incition to the flank incision an dbrought all 3 existing wires down.  We connected the two occipital leads to a two-into-one connecgtor.  We again checked those connections and torqued them into placde with their cuffs.  On the existing single wire, which was bifrontal, we placed a 30 cm extension with a cuff and torqued it into place. At this point we had three wires.  They were all showing appropriate connection impedances.  We then tunneled from that relaxing incision to the buttock incision, passed the wires down and connected them to the IPG, torqued into place and did several connection checks, they all appeared to be appropriate.  

The buttock incision had been opened sharply , dissected down a centimeter and a half and created a pocket to accept the IPG.  We irrigated all pockets, they all appeared to be nicely hemostatic. We placed the IPG in the pocket, coiled the excess wire deep to it and then closed the existing three incisions.  The previous left brow and left retoarticular incision had already been closed. The occipital wound was close dwith stitches.  



Any input is greatly appreciated!!!

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management


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## sriese (Aug 20, 2014)

Melissa.... I would have used  63650 63685-51


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## TCrem (Aug 20, 2014)

Melissa,

63685 is located in the cpt manual under "Neurostimulators (Spinal Nerve)" and 64555 is located in the manual under "Neurostimulators (Peripheral Nerve)". I think that if a spinal nerve stimulator was implanted, the associated code for the electrode placement would come from the spinal nerve neurostimulator section (as long as the electrode placement isn't bundled into the procedure by the payer's guidelines). This is the combination SRiese mentioned in their response. If it was a peripheral nerve stimulator, both the codes for the insertion of the implanted pulse generator and the electrodes placement would be located under the peripheral nerve neuorstimulator section (in that case, the codes might be 64590, 64555, and/or possibly 64575). 

Also, I think 64555 has an MUE value of 2. 

If you know the manufacturer of the IPG, go to their website. Often medical device companies provide coding/reimbursement info on their sites, and if they don't, you can call their customer service line for professionals and they may be able to connect you with someone who can give you guidance.

I know this wasn't the straight forward answer you were probably looking for, but I hope it helped a little. 

Trisha C.


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## Melissa Harris CPC (Aug 21, 2014)

Thank you Trisha.  We were the co-surgeon in this and my doc placed the electrodes, he didn't do the incisions etc.  So I am completely stumped!


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## dwaldman (Aug 22, 2014)

This looks like a technical case and a lot work to perform. Sorry to hear you have determine how to be reimbursed and the confusing 64575 versus 64555. It does use the word percutaneous when describing the placement, there not a incision over the site where the lead is placed I believe.

I did notice in the other response you received from TCrem/Trisha that 64555 has an MUE of 2.

After reading her mention that I look it up and it does only 2 from a Medicare perspective. 

Medically Unlikely Edits*

Facility 2 units of service per day under most circumstances  
Professional 2 units of service per day under most circumstances


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