codegirl0422
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PROCEDURE PERFORMED: InterStim placement.
INDICATIONS: The patient has decided to undergo InterStim implant placement because of failure of
extensive conservative approach with excellent testing results with I-Stim. I-Stim therapy for her
condition has been well established in English literature with approval of FDA for indications of
frequency, urgency, urge incontinence syndrome extensively. Published data is available for review in
literature in the United States and European countries as well as Asian countries. The possibility of: 1)
bleeding; 2) infection; 3) rejection; 4) need for re-do operation; 5) reprogramming needs were discussed.
Mechanism, mechanics and physical activities, ________ modules, and therapy were reviewed through
published data from major institutions and my personal data.
PROCEDURE: The patient was taken to the operating room, placed under anesthesia, then in prone
position appropriately. Area was prepped and draped in usual fashion in a meticulous way for surgery.
The patient received Vancomycin preoperatively along with Claforan to reduce risk of infection. The
Surgical team became ready, time was taken out. The area was prepped and draped in usual fashion in a
meticulous manner with a sterile drape to prevent and reduce the risk of infection of any kind.
In the middle of the spine in the center a Medtronic needle was placed. Using fluoroscopy in an AP
manner the midline was defined by surface marking. Then the needle was placed transversely to
demonstrate the intersciatic notch which was defined with the marker as well. This patient has had
multiple back surgeries, particularly with bone grafting and cages put in, which exacerbated actually her
voiding dysfunction with urgency and frequency. Her frequency is every 30 minutes, urgency is
tremendous and urge incontinence requires that she utilize multiple pads on a daily basis with restriction
of personal, social and sexual abilities.
Having surface marked after multiple attempts I was able to introduce Medtronic needle in the right side
in S3 foramen with accuracy using AP and lateral view. Testing showed a good toe response and bellows
response particularly indicating proper depth placement. Following this the stylet of the needle was
retrieved and a guide wire was introduced using lateral fluoroscopy control in an appropriate manner and
the needle was retrieved over the guide wire. A small incision was made around the guide wire. Then
obturator was introduced using lateral fluoroscopy control in an accurate manner and placed
appropriately. Having placed the obturator appropriately then the sheath along with the guide wire was
retrieved. The tine electrode was primed for placement purposes with proper angulation toward the toe
and introduced accurately using fluoroscopy control in a proper manner. AP and lateral views showed
proper placement with lateral deviation. After this testing was performed at level 1, 2, 3, level; level 1, 2,
3 responded well.
Then I was able to create a battery pocket on ipsilateral side four fingers breadth below the ischial crest
using appropriate anatomic landmarks. Incision was made about 4 cm length posterolaterally. Incision
was deepened through skin and subcutaneous tissue, deep fascia. Cautery was utilized for thorough
hemostasis and pocket was created in the deep fascia. Then the tunneler was introduced with a
subcutaneous tunnel starting from the entry site of the electrode to the battery site. Through the spaghetti
the electrode was traveled for connection to the battery. Connection was appropriately achieved using
Medtronic criteria and no impedance was noticed. The battery was placed in the pocket with irrigation
with antibiotic solution with insignia facing the surgeon. The pocket was closed for deep fascia using 2-0
Vicryl in a running fashion and 3-0 Vicryl for superficial fascia. Skin was approximated with 4-0 Vicryl
in a subcuticular manner and local anesthetic, Marcaine with lidocaine, was infiltrated along the surgical
sites. The entry site of the electrode was approximated with 4-0 Vicryl in a subcuticular manner
appropriately. In a meticulous manner then sterile drape was removed. One was able to utilize Steri-
Strips dressing and a 4 x 4 dressing.
Wound care was explained to the patient?s family members. She will not shower for four days, but
sponge bathe. She will go home on clindamycin and tramadol. She will continue home medications.
Next week the patient will have a visitation with Medtronic representative who will perform
programming for her device and changes as needed.
I got 64590 64581 95972. But I am being told we should only bill 64581 95972 that 64590 and 64581 has edits per Medicare and show they can't be billed together. The software did not show an edit and when I checked CCI, it doesn't show edit either. Thanks in advance for any help on this one.
INDICATIONS: The patient has decided to undergo InterStim implant placement because of failure of
extensive conservative approach with excellent testing results with I-Stim. I-Stim therapy for her
condition has been well established in English literature with approval of FDA for indications of
frequency, urgency, urge incontinence syndrome extensively. Published data is available for review in
literature in the United States and European countries as well as Asian countries. The possibility of: 1)
bleeding; 2) infection; 3) rejection; 4) need for re-do operation; 5) reprogramming needs were discussed.
Mechanism, mechanics and physical activities, ________ modules, and therapy were reviewed through
published data from major institutions and my personal data.
PROCEDURE: The patient was taken to the operating room, placed under anesthesia, then in prone
position appropriately. Area was prepped and draped in usual fashion in a meticulous way for surgery.
The patient received Vancomycin preoperatively along with Claforan to reduce risk of infection. The
Surgical team became ready, time was taken out. The area was prepped and draped in usual fashion in a
meticulous manner with a sterile drape to prevent and reduce the risk of infection of any kind.
In the middle of the spine in the center a Medtronic needle was placed. Using fluoroscopy in an AP
manner the midline was defined by surface marking. Then the needle was placed transversely to
demonstrate the intersciatic notch which was defined with the marker as well. This patient has had
multiple back surgeries, particularly with bone grafting and cages put in, which exacerbated actually her
voiding dysfunction with urgency and frequency. Her frequency is every 30 minutes, urgency is
tremendous and urge incontinence requires that she utilize multiple pads on a daily basis with restriction
of personal, social and sexual abilities.
Having surface marked after multiple attempts I was able to introduce Medtronic needle in the right side
in S3 foramen with accuracy using AP and lateral view. Testing showed a good toe response and bellows
response particularly indicating proper depth placement. Following this the stylet of the needle was
retrieved and a guide wire was introduced using lateral fluoroscopy control in an appropriate manner and
the needle was retrieved over the guide wire. A small incision was made around the guide wire. Then
obturator was introduced using lateral fluoroscopy control in an accurate manner and placed
appropriately. Having placed the obturator appropriately then the sheath along with the guide wire was
retrieved. The tine electrode was primed for placement purposes with proper angulation toward the toe
and introduced accurately using fluoroscopy control in a proper manner. AP and lateral views showed
proper placement with lateral deviation. After this testing was performed at level 1, 2, 3, level; level 1, 2,
3 responded well.
Then I was able to create a battery pocket on ipsilateral side four fingers breadth below the ischial crest
using appropriate anatomic landmarks. Incision was made about 4 cm length posterolaterally. Incision
was deepened through skin and subcutaneous tissue, deep fascia. Cautery was utilized for thorough
hemostasis and pocket was created in the deep fascia. Then the tunneler was introduced with a
subcutaneous tunnel starting from the entry site of the electrode to the battery site. Through the spaghetti
the electrode was traveled for connection to the battery. Connection was appropriately achieved using
Medtronic criteria and no impedance was noticed. The battery was placed in the pocket with irrigation
with antibiotic solution with insignia facing the surgeon. The pocket was closed for deep fascia using 2-0
Vicryl in a running fashion and 3-0 Vicryl for superficial fascia. Skin was approximated with 4-0 Vicryl
in a subcuticular manner and local anesthetic, Marcaine with lidocaine, was infiltrated along the surgical
sites. The entry site of the electrode was approximated with 4-0 Vicryl in a subcuticular manner
appropriately. In a meticulous manner then sterile drape was removed. One was able to utilize Steri-
Strips dressing and a 4 x 4 dressing.
Wound care was explained to the patient?s family members. She will not shower for four days, but
sponge bathe. She will go home on clindamycin and tramadol. She will continue home medications.
Next week the patient will have a visitation with Medtronic representative who will perform
programming for her device and changes as needed.
I got 64590 64581 95972. But I am being told we should only bill 64581 95972 that 64590 and 64581 has edits per Medicare and show they can't be billed together. The software did not show an edit and when I checked CCI, it doesn't show edit either. Thanks in advance for any help on this one.