Help with op note

[ardellt]

What code(s) would we bill for the following procedure.
The patient was placed in the prone position on the procedure table. Back was prepped and draped in standard sterile fashion. 1% lidocaine 15 mL total was used for local infiltration. Two incisions about 3 cm in length, were made over the left and right paraspinal area of the lumbar region laterally from postoperative scar. The incisions were carried through the skin and subcutaneous tissues toward the fascia. Hemostasis was obtained using electrocoagulation. Two 14-gauge Tuohy needles were advanced into the left and right paraspinal area of the lumbar region laterally from postoperative scar. Two 8 electrode leads were inserted through the Tuohy needles and Tuohy needles were withdrawn. Good position of the leads was confirmed with C-arm. Both leads were connected to temporary unit and complex programming of peripheral nerve stimulator leads was performed. The patient reported 100% coverage of the pain areas and was very satisfied with this coverage. At this point, both leads were attached to the fascia using anchoring devices and 0 Nurolon sutures. After additional local infiltration of 1% lidocaine, incision in the left paraspinal area of lumbar region was extended to left supragluteal area. Using blunt and sharp dissection, we created a sufficient size pocket to accommodate the generator. Using kit provided tunneling device, we brought a lead from the wound in right paraspinal area of lumbar region to the wound in the left supragluteal area. Both leads were connected to Restore Advanced Rechargeable generator and the generator was affixed to the fascia using 2 interrupted sutures of 0 Nurolon. Both wounds were irrigated using antibiotic solution and closed with interrupted sutures of 2-0 Vicryl. The subcutaneous tissue was approximated with a running suture of 3-0 Vicryl. Before final skin closure, we injected 20 mL of 0.25% Sensorcaine in skin edges. Skin was approximated with staples. Patient tolerated the procedure well.
diagnosis-post laminectomy syndrome
procedure done 5/15/12

[aaron.lucas]

It looks to me like 64565 for the leads and maybe 64590 for the generator? Any other thoughts anyone?

[dwaldman]

0282T

Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period

0283T

permanent, with implantation of a pulse generator

0284T

Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed

0285T

Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed

(Do not report 0282T - 0285T in conjunction with 64550 - 64595, 77002, 77003, 95970 - 95973)

Rationale

Four Category III codes have been established for reporting peripheral field stimulation. Peripheral field stimulation is a new technology for the treatment of chronic cervical, thoracic, or lumbar pain. Electrode leads are placed in subcutaneous tissue around the painful area, and electrical current is applied to create stimulation in the area, or "field," of pain. This technique is different from peripheral nerve stimulation, in which specific peripheral nerves are targeted. In peripheral field stimulation, a field of pain is targeted rather than specific nerves. The electrodes are placed in the skin either through an open or percutaneous approach. Imaging guidance is included, when performed.

Code 0282T describes implantation of trial electrode arrays and includes removal of the electrodes at the end of the trial period. Code 0283T is reported for permanent implantation of electrode arrays with implantation of a pulse generator. Revision or removal of the pulse generator or electrodes is reported with code 0284T and includes addition of new electrodes, when performed. Code 0285T describes electronic analysis of the pulse generator and includes reprogramming, when performed. An exclusionary parenthetical note precludes the reporting of codes 0282T - 0285T with the peripheral nerve neurostimulator codes 64550 - 64595, fluoroscopic guidance codes 77002 and 77003, or electronic analysis of neurostimulator pulse generator codes 95970 - 97973.

[aaron.lucas]

Playing devil's advocate here, I read this in the op report "...programming of peripheral nerve stimulator leads was performed." based on your rationale, the cat III codes are for "peripheral field stimulation", not "peripheral nerve stimulation". are there other codes that would be more appropriate in this case? it also mentions coverage of "pain areas", so maybe the documentation isn't good? (i.e. contradictory)?

[dwaldman]

The leads are being placed in the following regions

"Two incisions about 3 cm in length, were made over the left and right paraspinal area of the lumbar region laterally from postoperative scar. The incisions were carried through the skin and subcutaneous tissues toward the fascia. Hemostasis was obtained using electrocoagulation. Two 14-gauge Tuohy needles were advanced into the left and right paraspinal area of the lumbar region laterally from postoperative scar. Two 8 electrode leads were inserted through the Tuohy needles and Tuohy needles were withdrawn. Good position of the leads was confirmed with C-arm. Both leads were connected to temporary unit and complex programming of peripheral nerve stimulator leads was performed. "

Above is describing placing the leads in the field of painful area. There is not a specific peripheral nerve being addressed.