Wiki How many SCS leads can they bill? *help*

[betsycpcp]

I work for a payer and we have an outpatient hospital bill where they billed 3 units of C1778 (neurostimulator leads). The op report says they did a laminectomy and tried to put in a paddle lead, but due to scar tissue it wouldn't go in correctly. So they placed a percutaneous wire through the laminectomy lead left of midline at T7-8, then a second percutaneous wire was passed in a similar fashion by laminectomy and placed midline at T7-8. So basically it looks like they're billing for the paddle lead that had to be taken out because it wouldn't go to the right place, and the 2 percutaneous wires that were then placed instead. My question is, are they correct to bill for all 3 leads although only 2 were actually implanted in the end?

Thanks in advance for any help.

 

[dwaldman]

They incurred the cost for the 2 percutaneous leads/1 paddle lead. The paddle lead appears to be removed from the sterile packaging and attempted to be placed. The lead can not be reused. And from the facility perspective they have incurred the cost for this implant with the unforeseen ability to finalize the implantation by the physician. Also the time to perform the laminectomy and there is also the tunneling portion of the percutaneous leads to account for different aspect of the placement.

For facility billing you are asking should they be paid for the three implants, I believe the answer would be yes. Look at the Medicare payment methodology for a discontinued procedure. It is 100 of the APC allowable when modifier 74 (discontinued procedure following induction of anesthesia) is placed on the CPT code.

I would allow the payment for the implants in question given the extent of the procedure that was carried out and the reason for not finalization of the implantation following procedure end time.

 

[betsycpcp]

I was kind of thinking along the same lines. Thank you for the clear explanation of your rationale.