Anesthesia Coding Alert

READER QUESTION ~ V53.09 Does Apply to Stim Removal

Question: What diagnosis applies to removing a spinal cord stimulator (SCS) system? The patient requested it because she couldn't have an MRI of her knee when the SCS was in place.

New Mexico Subscriber
  
Answer: Coders differ in their opinions of how to code these cases, especially because the patient requested the removal. So you have two options:

Option 1: Use V53.09 (Fitting and adjustment of other devices related to nervous system and special senses). The descriptor says, "fitting and adjustment," which seems misleading to some coders. But if you look at the section head, you'll see that V53 is "Fitting and adjustment of other device" and has the notation "Includes removal of device, replacement of device."

Option 2: Report 996.2 (Mechanical complication of nervous system device, implant and graft [to be used to indicate intolerance of the device by the patient or failure of equipment/loss of effectiveness]). Coders who like this option say you can look at the case as "patient intolerance" because she requested the removal.

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