Carol E
Contributor
I'm trying to determine the correct CPT codes for the removal of a spinal cord stimulator (SCS) system, including:
The documentation doesn't specify how the device was originally implanted, and I’m not very familiar with all the components of an SCS system. Any guidance on correct coding or how to approach this based on limited documentation would be appreciated. Op report description is as follows:
DESCRIPTION OF PROCEDURE: Using the patient's previous stab incisions, an incision corresponds with stimulator battery through the skin and subcutaneous tissue down to the level of the spinal cord stimulator battery. Spinal cord stimulator battery was identified and removed. The patient's previous leads were identified and removed. We undid the area where the leads were tacked down to the fascia removing two spinal cord stimulator paddle leads and all the wires. The patient's wounds were all thoroughly irrigated with normal saline. Meticulous hemostasis was obtained. The deep fascial layers were closed using a 0 Vicryl stitch, subcutaneous tissue was closed using a 2-0 Vicryl stitch, and skin was closed using staples. The patient's wounds were cleaned, dried, and dressed with Dermabond, Telfa, and Tegaderm dressing. The patient was awoken from general endotracheal anesthesia with no complications and taken to the postoperative holding area doing well.
- Battery
- 2 paddle leads
- Associated wires
The documentation doesn't specify how the device was originally implanted, and I’m not very familiar with all the components of an SCS system. Any guidance on correct coding or how to approach this based on limited documentation would be appreciated. Op report description is as follows:
DESCRIPTION OF PROCEDURE: Using the patient's previous stab incisions, an incision corresponds with stimulator battery through the skin and subcutaneous tissue down to the level of the spinal cord stimulator battery. Spinal cord stimulator battery was identified and removed. The patient's previous leads were identified and removed. We undid the area where the leads were tacked down to the fascia removing two spinal cord stimulator paddle leads and all the wires. The patient's wounds were all thoroughly irrigated with normal saline. Meticulous hemostasis was obtained. The deep fascial layers were closed using a 0 Vicryl stitch, subcutaneous tissue was closed using a 2-0 Vicryl stitch, and skin was closed using staples. The patient's wounds were cleaned, dried, and dressed with Dermabond, Telfa, and Tegaderm dressing. The patient was awoken from general endotracheal anesthesia with no complications and taken to the postoperative holding area doing well.