SCCL5558
Guest
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 TJ had the leads slightly withdrawn on 3/4/13 during the trial to obtain an improved stimulation pattern.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 The leads were then withdrawn easily and without difficulty.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.
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 TJ had the leads slightly withdrawn on 3/4/13 during the trial to obtain an improved stimulation pattern.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 The leads were then withdrawn easily and without difficulty.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.