kseeg23
Networker
I need help coding this procedure! It's a removal of an SCS but I'm unsure if one code sums it all up (63661) or if another is needed (63688). These SCS CPT codes all seem the same to me. Any help as far as clarification would be greatly appreciated.
PRE-PROCEDURE EVALUATION: Patient states he has been NPO for at least 4 hours, has a driver, denies current illness, infection or recent surgery, and has signed a procedure consent form. Patient states that he has not taken any anticoagulants in the last 14 days. Patient reports pre-procedure anxiety and is requesting sedation. PT/INR was not performed.
VITALS: BP: 161/89 HR: 83 Temp: 97.7 O2 Sat: 100 CURRENT PAIN SCORE: On a VAS scale from 0-10, the patient rates their pain currently at a 0.
AVERAGE PAIN SCORE: Patient rates their pain on average at a 3.
Anesthesia: An IV catheter was placed and made secure in the right hand . 1gram of Ancef was given intravenously prophylactically. The following medications were given for sedation by intravenous injection: fentanyl 1ml versed 1ml . Sedation administration start time: 07:55 AM . Sedation end time: 08:26 AM. Prior to procedure an evaluation was performed. The procedure was explained to the patient. Initially a skeletal model was used to give a detailed procedure explanation. An instructional video was also shown demonstrating the procedure. Potential complications including death, nerve damage, temporary or permanent paralysis, bleeding, infection, headache and/or other serious or life threatening compliactions were explained to the patient. No guarantee of benefits were given. The patient agreed to have the procedure and signed the consent. The patient was taken to the operating room and placed in the prone position. Standard non-invasive monitors were then applied. Confirmation of the procedure to be performed was obtained from the patient. All surgical staff involved in the procedure wore standard sterile gown, hat, mask, and gloves. The skin overlying the operative field was prepped with duraprep and draped in a sterile fashion. A standard lap drape was placed over the operative field. Under flouroscopic guidance the anchors were located and an incision was made. The existing pocket for the generator was located and another incision was made. The leads were disconnected from the generator. The battery and the leads were then removed. The incisions were then closed with staples and 2.0 vicryl and covered with mastisol, steri-strips and protective gauze and tape. The patient tolerated the procedure well and was brought to the recovery area in awake and in hemodynamically stable condition.
PRE-PROCEDURE EVALUATION: Patient states he has been NPO for at least 4 hours, has a driver, denies current illness, infection or recent surgery, and has signed a procedure consent form. Patient states that he has not taken any anticoagulants in the last 14 days. Patient reports pre-procedure anxiety and is requesting sedation. PT/INR was not performed.
VITALS: BP: 161/89 HR: 83 Temp: 97.7 O2 Sat: 100 CURRENT PAIN SCORE: On a VAS scale from 0-10, the patient rates their pain currently at a 0.
AVERAGE PAIN SCORE: Patient rates their pain on average at a 3.
Anesthesia: An IV catheter was placed and made secure in the right hand . 1gram of Ancef was given intravenously prophylactically. The following medications were given for sedation by intravenous injection: fentanyl 1ml versed 1ml . Sedation administration start time: 07:55 AM . Sedation end time: 08:26 AM. Prior to procedure an evaluation was performed. The procedure was explained to the patient. Initially a skeletal model was used to give a detailed procedure explanation. An instructional video was also shown demonstrating the procedure. Potential complications including death, nerve damage, temporary or permanent paralysis, bleeding, infection, headache and/or other serious or life threatening compliactions were explained to the patient. No guarantee of benefits were given. The patient agreed to have the procedure and signed the consent. The patient was taken to the operating room and placed in the prone position. Standard non-invasive monitors were then applied. Confirmation of the procedure to be performed was obtained from the patient. All surgical staff involved in the procedure wore standard sterile gown, hat, mask, and gloves. The skin overlying the operative field was prepped with duraprep and draped in a sterile fashion. A standard lap drape was placed over the operative field. Under flouroscopic guidance the anchors were located and an incision was made. The existing pocket for the generator was located and another incision was made. The leads were disconnected from the generator. The battery and the leads were then removed. The incisions were then closed with staples and 2.0 vicryl and covered with mastisol, steri-strips and protective gauze and tape. The patient tolerated the procedure well and was brought to the recovery area in awake and in hemodynamically stable condition.
