Urology Coding Alert

Question: Would the following sacral nerve neurostimulator implant of electrode array procedure be considered percutaneous or open? I am thinking this should be 64561 since the needle was utilized.

Diagnosis: Overactive bladder.

Procedure: Foramen needle was introduced near sciatic notch and sacral midline to identify and penetrate the S3 foramen. Needle depth adjusted with fluoroscopy, and position confirmed by perineum lift and observing great toe plantar flexion with external test stimulator. Foramen needle stylet was removed, and directional guide was fluoroscopically confirmed. Peripheral incision was made, and the lead introducer sheath guided over it into the foramen, ensuring marker didn’t extend beyond sacrum’s front edge. Dilator and directional guide were removed, and lead was placed through introducer sheath to first white line. Its position was checked fluoroscopically, further introduced until the electrode array was visible below sacrum. Electrode’s positions confirmed by observing great toe’s plantar flexion. Introducer sheath was retracted, deploying tined leads into pre-sacral tissue under continuous fluoroscopy. Further incision was made into subcutaneous tissue posterior to iliac crest lateral to sacrum. Blunt dissection was performed until gluteal fascia was identified and hemostasis achieved with electrocautery. A tunneling tool was used to guide lead from the exit site to incised pocket, and the lead was pulled out of pocket site. New IPG battery was retrieved, lead was inserted and secured with hex wrench. The IPG battery was placed back into the pocket with the InterStim lead wire underneath. Programming head was sterilely covered and placed over neurostimulator to confirm proper lead connection and normal parameters.

AAPC Forum Participant

Answer: “I agree with coding 64561 [Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed], which is meant for the percutaneous implantation of a neurostimulator electrode array of the sacral nerve,” says John Piaskowski, CPC-I, CPMA, CUC, CRC, CGSC, CGIC, CCC, CIRCC, CCVTC, COSC, specialty medicine auditor at Capital Health in Trenton, New Jersey, and AAPC consultant and committee chair. “Because the provider used fluoroscopic guidance throughout the surgery, and incisions were only made to the fascia, not exposing the sacral foramen as required for an open procedure, 64561 is appropriate in this case. Since the operation was technically at the subcutaneous layer, it aligns more with the definition of percutaneous,” says Piaskowski.

“In addition, CPT^® code 64595 (Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver) is reported in addition to CPT^® code 65461 to cover the replacement in the IPG battery and insertion back into the pocket site,” says Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, urology coding expert and consultant in Glen Burnie, Maryland.