# Neuro Stim



## Melissa Harris CPC (Feb 20, 2014)

I need help coding this procedure for nerve stimulator trial with 4 leads.

PROCEDURE: Boston Scientific NERVE STIMULATOR TRIAL

DIAGNOSIS:   
722.4 - Intervertebral Disc Degeneration Cervical, 723.1 - Cervicalgia
INDICATIONS:Occipital Headache, Chronic Axial Neck Pain  
ANESTHESIA:  Local/Conscious sedation

DESCRIPTION OF PROCEDURE:  With written and informed consent obtained, risk and benefits were discussed including but not limited to infection, post dural headache, temporary weakness/numbness of the arms, bone, nerve, spine damage, bleeding in the spine if taking ASA, NSAIDS, or blood thinners which can cause damage to the the spinal cord which can result in paralysis or death.  Benefits are include pain relief.  An IV was placed in the Left Antecubital  and 1gram of Cefazolin was given in 250ml of Normal Saline. Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse. The patient was then brought into the operating room.  With monitors in place the patient was placed prone on the fluoroscopic operating room table.  The area of the patient's neck and back of the head was first scrubbed, then prepped with alcohol, followed by betadine and drapped in a sterile surgical fashion.  Strict sterile OR technique was followed for this procedure.
The occiput was then visualized.  A skin wheal was raised just in the midline just below the inion with 4mL of 1% Lidocaine.   Then a 14 gauge thuohy epidural needle was passed through the skin wheal and directed toward the right mastoid process.  Once the  tissue was entered,  an 8 electrode spinal cord stimulator trial lead from Boston Scientific, model #SC-2352-50E, Lot # 381419 was advanced through the needle toward the inion fluoroscopically. AP view reveal that the 8 electrode lead was placed between the inion and the right mastoid process. 

Then a second 14  gauge thuohy epidural needle was passed through the skin wheal and directed toward the left mastoid process.  Once the  tissue was entered,  a second 8 electrode spinal cord stimulator trial lead from  Boston Scientific , model #SC-2352-50E, Lot # 382962 was advanced through the needle toward the left inion  fluoroscopically. AP view reveal that the 8 electrode lead was placed in the space between the inion and the left mastoid process.

Then I raised two skin wheals with 1% lidocaine, 4 mL at each skin wheal over the cervical paraspinal musculature at the C2 level approximately 2 cm from the midline.

I then directed a 14-gauge Touhy epidural needle downward through the skin and passed in a vertical direction parallel to the spinous processes just underneath the skin in the subcutaneous tissue spanning from C2-C4 on the right-hand side. I then did the same thing on the left-hand side with another 14-gauge Touhy epidural needle.  I then inserted Boston Scientific spinal cord stimulator electrodes into each needle and fluoroscopically confirmed the electrode position as being between C2 and C4 in a vertical position just underneath the skin. The third 8 electrode spinal cord stimulator trial lead from Boston Scientific , model #SC-2352-50E, Lot # 381430. The fourth 8 electrode spinal cord stimulator trial lead from  Boston Scientific , model #SC-2352-50E, Lot # 382815. These were parallel to one another and to the spinous processes in the midline.



 At this point, under my direct supervision , the Boston Scientific  representative began trial stimulation.  Once this was deemed satisfactory, the needle and stylettes were removed from the patient, leaving the four 8 electrode leads in place. The leads were then fixed to the skin using a small plastic cuff over the exterior portion of the lead.  A 2-0 silk suture on a curved cutting needle was placed through the cuff to the skin.  Bacitracin ointment was applied to the puncture wounds and the whole system was held in place with benzoin and clear occlusive bandages. The patient was then brought to the recovery area in stable condition where once again stimulation was programmed under my direct supervision and with my input.  The patient was given instructions to follow-up in the following week for stimulator removal and/or any problems that might arise. 

64555 x 4 with 51  modifiers on the latter 3 codes?   I received a denial on the latter two codes for duplicate.  

Thank you!

Melissa Harris, CPC


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## Natesmary (Feb 20, 2014)

If four separate percutaneous sites were addresssed wouldn't modifer 59 be more appropriate?


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## dwaldman (Feb 20, 2014)

This appears to be percutaneous subcutaneous field stimulation. You need to report 0282T. It does state a specific peripheral nerve is targeted but a field area. Below is from AMA CPT Changes 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 
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

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


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 electrodes are placed in the skin either through an open or percutaneous approach. Imaging guidance is included, when performed.

Code 0282T describes implantation of trial electrode arrays and includes removal of the electrodes at the end of the trial period. Code 0283T is reported for permanent implantation of electrode arrays with implantation of a pulse generator. Revision or removal of the pulse generator or electrodes is reported with code 0284T and includes addition of new electrodes, when performed. Code 0285T describes electronic analysis of the pulse generator and includes reprogramming, when performed. An exclusionary parenthetical note precludes the reporting of codes 0282T - 0285T with the peripheral nerve neurostimulator codes 64550 - 64595, fluoroscopic guidance codes 77002 and 77003, or electronic analysis of neurostimulator pulse generator codes 95970 - 97973.

Clinical ExampleClinical Example (0282T)

A 66-year-old male who previously underwent a lumbar discectomy presents with chronic low back pain without radiculopathy. He has no lower extremity symptoms. He denies any bowel or bladder symptoms. Physical examination reveals no neurological abnormalities but lumbar spine range of motion is restricted by pain. He complains of low back pain upon palpation at approximately L3, L4, and L5 bilateral paraspinal muscles. Plain film radiographs of the lumbar spine demonstrated degenerative disc disease and spondylosis at multiple levels. Lumbar spine MRI demonstrates multilevel disc bulges and mild multilevel facet hypertrophy. Despite treatment with physical therapy, nonsteroidal anti-inflammatory medications, opiate therapy, facet joint steroid injections, and epidural steroid injections, no improvement in pain or function was obtained. Due to the patient's failure with conservative treatments and his persistent complaints of diffuse low back pain, a trial of peripheral field stimulation is indicated to attempt to relieve patient's pain and improve function.

Description of Procedure (0282T)

Prior to sedation, the area of pain is carefully outlined and patient receives preoperative intravenous antibiotics. Under sterile conditions, with minimal sedation and appropriate monitoring, a needle is placed subcutaneously, using a small amount of lidocaine at the insertion point. Subcutaneous electrode leads are placed centrally in the area of greatest pain. On-the-table stimulation ensures the correct depth of the leads and adequate stimulation over the area of pain. The leads are then sutured to the skin and dressing is applied. Average trial duration is five to seven days.

Clinical ExampleClinical Example (0283T)

A 66-year-old male who previously underwent lumbar discectomy presents with chronic low back pain without radiculopathy. He has no lower extremity symptoms. He denies any bowel or bladder symptoms. Physical examination reveals no neurological abnormalities but lumbar spine range of motion is restricted by pain. He complains of low back pain upon palpation at approximately L3, L4, and L5 bilateral paraspinal muscles. Plain film radiographs of the lumbar spine demonstrated degenerative disc disease and spondylosis at multiple levels. Lumbar spine MRI demonstrates multilevel disc bulges and mild multilevel facet hypertrophy. Despite treatment with physical therapy, nonsteroidal anti-inflammatory medications, opiate therapy, facet joint steroid injections, and epidural steroid injections, no improvement in pain or function was obtained. Due to the patient's failure with conservative treatments and his persistent complaints of diffuse low back pain, he had undergone a trial of peripheral field stimulation and received significant relief during the trial. Permanent placement of a peripheral field stimulator is indicated.

Description of Procedure (0283T)

Prior to sedation, the area of pain is carefully outlined and patient receives preoperative intravenous antibiotics. Under sterile conditions, with minimal sedation and appropriate monitoring, a needle is placed subcutaneously, using a small amount of lidocaine at the insertion point. Subcutaneous electrode leads are placed centrally in the area of greatest pain and in the same region as the trial electrode leads had been placed. On-the-table stimulation ensures the correct depth of the leads and adequate stimulation over the area of pain. The leads are then sutured to the fascia. The pulse generator or receiver is then implanted by a separate incision by establishing a subcutaneous pocket. The electrode array is tested to verify proper connection and the device is programmed to begin stimulation. The wound is closed and dressing is applied.

Clinical ExampleClinical Example (0284T)

A 66-year-old male presents with an implanted peripheral field stimulator for pain control, which initially provided good coverage and control of pain in the affected area. Over time, the stimulator no longer provided coverage to the affected area and removal of the electrode array and generator is indicated.

Description of Procedure (0284T)

Prior to sedation, the area of pain is carefully outlined and patient receives preoperative intravenous antibiotics. Under sterile conditions, with minimal sedation and appropriate monitoring, the old skin incision of the generator is reopened and the wound checked for hemostasis. The old generator is dissected out of its subcutaneous pocket and delivered onto a sterile towel. The lead terminals are carefully disconnected from the expired generator. The subcutaneous pocket is then irrigated and closed. Dressing is applied. The anchoring site of the previous stimulator lead is localized and the overlying soft tissue structures are anesthetized. An incision is made to expose the leads. The lead is cut at the site and removed via gentle traction. The incision is closed and dressing is applied.

Clinical ExampleClinical Example (0285T)

A 66-year-old male has undergone implantation of a peripheral field stimulator for pain control of his low back pain. Analysis and programming of the pulse generator to correctly address the region of his pain is indicated.

Description of Procedure (0285T)

Electronic analysis and programming of an implanted permanent single array electrode system and subcutaneous generator/transmitter is performed. The physician tests a limited combination of the implant parameters while assessing the degree of symptom and side effect improvement or worsening after each programming change.


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## dwaldman (Feb 20, 2014)

Sorry I meant it does not appear a specific nerve is being targeted a field or area of pain.


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