Wiki Removal Spinal Cord Stimulator Leads

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SCCL5558

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Can someone help with coding this? I see X-rays in the report but not sure if that would warrant a separate code.

Thanks for looking!

REMOVAL TRIAL SPINAL CORD STIMULATOR LEADS

The patient was brought to the operative area, situated prone on the fluoroscopy table, and the dressings over the percutaneous leads were inspected and found intact. TJ had the leads slightly withdrawn on 3/4/13 during the trial to obtain an improved stimulation pattern. Spot Xray's were taken showing the insertion site at T12-L1 and the lead tips with first contact just above the T6 superior endplate. The sterile Opsites were well adherent and the chlorhexadine discs were in place. The dressings were removed and the sutures removed from the leads utilizing sterile technique and suture removal scissors and forceps. The leads were then withdrawn easily and without difficulty. The tips were intact and he had no symptoms or paresthesias with removal. Antibiotic ointment was placed over the puncture sites and sterile dressings.
He was advised not to immerse under water today or tomorrow but showering was acceptable. He was further advised that if he developed any signs of infection, neurologic changes such as new numbness or weakness or any other significant acute change he should call us immediately.
 
The spot xrays reference appears it was with the fluoroscopy machine which would be inclusive to the trial removal reported with post op code 99024. If this was reference to plain film xrays, there is not appropriate documentation such as separate formal report or number views. If performed in a hospital setting, the interpretation would already be contracted to another physician group if you are inquiring about physician portion.

As seen in the previous response you received, it would not be appropriate to report 63661 for the removal of trial spinal cord stimulator leads.

the February 2010 CPT Assistant article on pain medicine, the first complete paragraph in the right-hand column of page 10 read:

...The guidelines also indicate that CPT codes 63661 or 63663 should not be reported when removing or replacing a temporary percutaneously placed array for an external generator. The replacement of a temporary placed array(s) with a permanent array or paddle is included in the insertion procedure and is not separately reportable. If the temporary array is removed without permanent placement, it is a subsequent Evaluation and Management (E/M) service, which is typically within the global period of the initial placement and therefore not reported.
 
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