I have a case where the surgeon placed two trial electrodes, did stimulation, and then had issues and found the leads were not properly placed and had to be removed.
Our reimbursement for the actual trial leads comes from Medicare in the form of payment on CPT 63650 not the HCPCS. We bill this twice as there were two leads put in.
Due to this situation I would be adding a -74 but my understanding is that I can only do that on one CPT. In this case it really was two placed and two terminated.
Has anyone ever billed : 63650-74 x 2 and had success with Medicare paying for both???
Thank you,
Jorja
OP note below:
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed prone on an x-ray table. It was difficult to position her due to her extensive fusions in the past, and it was impossible to get a good curvature in her lumbar spine. Several attempts were made. Nonetheless, when the anesthesiologist was comfortable with her condition, the patient's whole back was sterilely prepped and draped. Fluoroscopic study was done of her whole spine. There seemed to be a solid lateral fusion at the four lower lumbar segments at the wide laminectomy scars. The level immediately above it, which would be L2, seemed to have had laminectomy but no fusion. It was difficult to reconstruct exactly what was done for this patient except that she never had any positive response.
It was decided to go at a higher level entrance first in the sense that the patient had levels above the surgery that were very narrow. The T12-L1 space was attempted first. A 14-gauge epidural needle with a bent tip was placed percutaneously under fluoroscopic guidance with loss-of-resistance at L1-2. A myelography procedure injection done produced an epidurogram to confirm placement. The dye was then washed out with normal saline solution. An electrode array with 16 contacts was passed through the needle and advanced up to the top of T7 slightly to the right of the midline. The second needle was placed in the exact same way. It was kept as shallow as possible. There was some difficulty, but eventually, there was loss-of-resistance and another myelography procedure injection produced an epidurogram showing good placement. A second electrode was advanced up the epidural space under fluoroscopic guidance to lie parallel to the first electrode. The patient was allowed to wake up at this point, and intraoperative spinal cord stimulation was done. Unfortunately, the stimulation pattern was quite bizarre and also uncomfortable for the patient.
A lateral x-ray view was taken which explained this situation. Both electrode arrays were in the anterior epidural space. They were then removed, and several attempts were made to change the situation by adjusting the directions of the needles as well as the angle. One could not go at a very shallow angle, the best probably 45 degrees because of the patient's anatomy, and each time, no matter where the space was entered, the electrodes coiled around and became anterior. It was decided to try another level, and we first went up to T11-12. All her disk spaces were extremely desiccated with extensive degenerative changes. At T12-L1, two similar needle attempts were made at a shallow angle as much as possible. The skin was anesthetized in all positions. Myelography procedure injection was done again to confirm placement. Actually at that level, only one electrode could be placed, but again, on lateral view, it was in the anterior epidural space. It was then elected as a last resort to try the L1-2 space that seemed to have had a laminectomy but could also just present a large translaminar space. The skin was anesthetized 5 cm inferior to this, and a 14-gauge curved tip needle was advanced percutaneously at as shallow an angle as possible with loss-of-resistance at L1-2. An electrode was placed through L1-2 and was advanced up the midline for some distance. To confirm placement, a lateral picture was taken which again showed this electrode to be in the posterior epidural space with no improvement in the position no matter what was tried. The procedure lasted more than three hours, and it was impossible with all of the experience and skill that I believe I have to place the electrode successfully. The procedure was stopped, and there was a decision made to abandon the procedure. The patient's back was cleaned, and Steri-Strips were used at the entrance sites. The patient did get prophylactic antibiotics.
Our reimbursement for the actual trial leads comes from Medicare in the form of payment on CPT 63650 not the HCPCS. We bill this twice as there were two leads put in.
Due to this situation I would be adding a -74 but my understanding is that I can only do that on one CPT. In this case it really was two placed and two terminated.
Has anyone ever billed : 63650-74 x 2 and had success with Medicare paying for both???
Thank you,
Jorja
OP note below:
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed prone on an x-ray table. It was difficult to position her due to her extensive fusions in the past, and it was impossible to get a good curvature in her lumbar spine. Several attempts were made. Nonetheless, when the anesthesiologist was comfortable with her condition, the patient's whole back was sterilely prepped and draped. Fluoroscopic study was done of her whole spine. There seemed to be a solid lateral fusion at the four lower lumbar segments at the wide laminectomy scars. The level immediately above it, which would be L2, seemed to have had laminectomy but no fusion. It was difficult to reconstruct exactly what was done for this patient except that she never had any positive response.
It was decided to go at a higher level entrance first in the sense that the patient had levels above the surgery that were very narrow. The T12-L1 space was attempted first. A 14-gauge epidural needle with a bent tip was placed percutaneously under fluoroscopic guidance with loss-of-resistance at L1-2. A myelography procedure injection done produced an epidurogram to confirm placement. The dye was then washed out with normal saline solution. An electrode array with 16 contacts was passed through the needle and advanced up to the top of T7 slightly to the right of the midline. The second needle was placed in the exact same way. It was kept as shallow as possible. There was some difficulty, but eventually, there was loss-of-resistance and another myelography procedure injection produced an epidurogram showing good placement. A second electrode was advanced up the epidural space under fluoroscopic guidance to lie parallel to the first electrode. The patient was allowed to wake up at this point, and intraoperative spinal cord stimulation was done. Unfortunately, the stimulation pattern was quite bizarre and also uncomfortable for the patient.
A lateral x-ray view was taken which explained this situation. Both electrode arrays were in the anterior epidural space. They were then removed, and several attempts were made to change the situation by adjusting the directions of the needles as well as the angle. One could not go at a very shallow angle, the best probably 45 degrees because of the patient's anatomy, and each time, no matter where the space was entered, the electrodes coiled around and became anterior. It was decided to try another level, and we first went up to T11-12. All her disk spaces were extremely desiccated with extensive degenerative changes. At T12-L1, two similar needle attempts were made at a shallow angle as much as possible. The skin was anesthetized in all positions. Myelography procedure injection was done again to confirm placement. Actually at that level, only one electrode could be placed, but again, on lateral view, it was in the anterior epidural space. It was then elected as a last resort to try the L1-2 space that seemed to have had a laminectomy but could also just present a large translaminar space. The skin was anesthetized 5 cm inferior to this, and a 14-gauge curved tip needle was advanced percutaneously at as shallow an angle as possible with loss-of-resistance at L1-2. An electrode was placed through L1-2 and was advanced up the midline for some distance. To confirm placement, a lateral picture was taken which again showed this electrode to be in the posterior epidural space with no improvement in the position no matter what was tried. The procedure lasted more than three hours, and it was impossible with all of the experience and skill that I believe I have to place the electrode successfully. The procedure was stopped, and there was a decision made to abandon the procedure. The patient's back was cleaned, and Steri-Strips were used at the entrance sites. The patient did get prophylactic antibiotics.