Paddle lead for SCS trial

[betsycpcp]

What code should be used for implantation of a paddle lead for a spinal cord stimulator trial? The doctor's notes state that the plan would be to do a "small hemilaminotomy" in the upper thoracic spine and drive a percutaneous lead to the cervical region on the left side. The lead would be connected to an extension that can be externalized. If the trial is positive the extension is removed and the permanent generator and internal extension are implanted. If the trial is not positive they can remove the percutaneous lead.

The codes suggested by the doctor's coder are 63655 for the trial, and on a later date if the trial is successful, 63662 for removal of the external lead extension and 63685 for implantation of the generator, plus 95972 for programming.

I can't find anything about the coding for SCS trial using a paddle that is percutaneously placed. 63650 wouldn't include the hemilaminotomy (or hemilaminectomy), and 63655 isn't percutaneous. Also 63662 doesn't seem appropriate for removing the lead extension- I know if they did a normal percutaneous electrode array they couldn't charge for removing it after the trial- is this also true when it's a paddle lead via hemilaminotomy?

 

[SharonCollachi]

I would ask your equipment rep. We haven't done these in several years, but at that time, the cheat sheet I started from was given to me by the rep.

I would say the implant is 63655, because a hemilaminotomy is a laminectomy on one side. I don't recall what is included with each procedure, but I think your coder is probably correct.

 

[betsycpcp]

Thanks - I never see these and I found several studies on these but nothing official about how to code them.

 

[dwaldman]

I know you already received a response and had ruled out using CPT 63662 but I would go back to the individual that had provided CPT 63662 and point out: It seems it would be incorrect to report 63662 for removal a external lead extensions. Furthermore, there is nothing to support that if that trial fails that CPT 63662 can be reported since it is not internalized system for a removal of paddle lead trial. Since a trial to permanent paddle lead procedure is not described by AMA, it might be hard for the provider to grasp that CPT 63662 is not used but it does not appear consistent with their intent of how they structured removal and revision/replacement codes.
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051561/#:~:text=A%20screening%20trial%20of%20SCS,a%20permanent%20spinal%20cord%20stimulator.&text=An%20alternative%20for%20patients%20who,implantation%20of%20permanent%20paddle%2Dleads

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Permanent Paddle-lead Trial for Spinal Cord Stimulation

"An alternative for patients who are deemed poor candidates for percutaneous trials is screening using surgical implantation of permanent paddle-leads. We present a report of 12 patients at our institution who underwent permanent surgically-implanted paddle-lead trials for SCS."
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A paddle lead "trial to permanent" style procedure is not described by the AMA and NDC for Medicare only mentions a temporary trial as: " Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. "

AMA CPT Assistant April 2011

"Code 63685 includes the creation of a subcutaneous pocket made to house the stimulator and tunneling of the electrodes to the pocket "

To further clarify, the removal of a “temporary” percutaneous catheter array is included in code 63650. But, the removal of a “permanent” percutaneous catheter array is not inclusive in code 63650, and should, therefore, be reported using code 63661. Reporting it thus is appropriate regardless of whether the procedures were performed at the same or different spinal level(s). It would not be appropriate to report code 63664, Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed, because neither this type of electrode plate nor paddle was previously in place. Code 63664 would only be used if a previous permanent (internalized system) array of neurostimulator electrodes had been placed via either laminotomy or laminectomy, and was now being revised or replaced to improve efficacy.


AMA CPT Assistant August 2010

Use of Codes 63661, 63662, 63663, and 63664 Code 63661 would be reported for removal of a permanent (internalized system) spinal neurostimulator electrode percutaneous array(s) that has ceased to function, become infected, or become problematic for the patient. As stated in the parenthetical instructions, removal codes 63661 and 63662, Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed, are not reported in addition to codes 63663 or 63664. The work of removing the existing permanent lead array is valued within the code for replacement (63663, 63664), and is therefore, not reported separately. Code 63663, Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed, is reported to describe the revision or replacement of a previously placed percutaneous (permanent, internalized system) electrode array (code 63650). Code 63664, Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed, is reported to describe the revision or replacement of a previously placed (permanent, internalized system) electrode plate or paddle (code 63655). u

 

[betsycpcp]

There are good points -- I work for the payer (workers' comp) and this was part of a prior auth request. I just checked and we have only received the hospital bill so far -- they billed 63655 only. As it turns out, the op report says the original plan was to do a hemilaminotomy and implant percutaneous leads but they were unsuccessful in getting percutaneous leads to the right location so they converted it to an open paddle trial. So 63655 is fine. We haven't received bills for the removal yet but we did get an op report and it says the trial was not successful. They removed not only the extension leads but the paddle which had been placed via hemilaminectomy, so it seems to fit with 63662.
I'll keep your post handy for when the bills come in and I'll read the op reports in more detail.
Thanks for your reply!