Could anyone of yuo help me to code this following report?
My main doubt is shd we code this as
64581 or
64581 and 64581-59
along with
64590
95972
76000
This is a female with history of urgency and frequency who underwent a test stim and did well. She is now for a permanent implant. She understands the risks of bleeding, infection, the fact that it might not work, etc., and agrees to procedure.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and after adequate IV sedation, was placed on the operating room table in a prone position. Her buttocks were taped apart and she was prepped by the clock for 15 minutes. She was then draped in a sterile fashion, 1% lidocaine was injected, 9 cm up from the tip of the coccyx, 2 cm out, and 2 cm up, using a C-arm that was draped under fluoroscopic guidance the 3.5 inch needle was inserted into the left S3 foramen and under fluoroscopic guidance was advanced to the level of the posterior table of the sacrum, but not through it. Once there, it was tested, there was good bellows and good big toe response and so the stylet was placed through this. A small incision was made, the dilator was inserted and again care was taken not to perforate the posterior table.
The dilator was advanced to the level just flush to the posterior table. The introducer was removed from the dilator and the electrode was inserted. __________ three of the electrodes visible beneath the sacrum. They were then tested again. There was good bellows and good plantar flexion of the great toe. Using local, further incision was made over the right iliac crest lateral to the sacrum Blunt dissection was used until the gluteal fascia was identified. Hemostasis was controlled. The pocket was irrigated with gentamicin solution using the tunnelling tool starting from the insertion site to the pocket, first injecting subcutaneously the tunnelling tool was passed and the lead was passed into the pocket. The neurostimulator was then attached. Once the metal lines were aligned the blue leads were clearly visible in the distal portion, single setscrew was tight. The nerve stimulator was then programed to pulse width of 210, rate of 14 that was tested, impedances were confirmed to be within normal limits greater than 50 and less then 4000. The wound was irrigated with gentamicin solution. The subcuticular flap was closed with 4-0 chromic sutures. The skin was closed with 4-0 Monocryl subcuticular. The smaller incision was Dermabonded shut and the larger incision Steri-Stripped, covered with a sterile dressing. The patient was flipped supine and taken to the recovery room in good condition.
Thanks
My main doubt is shd we code this as
64581 or
64581 and 64581-59
along with
64590
95972
76000
This is a female with history of urgency and frequency who underwent a test stim and did well. She is now for a permanent implant. She understands the risks of bleeding, infection, the fact that it might not work, etc., and agrees to procedure.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and after adequate IV sedation, was placed on the operating room table in a prone position. Her buttocks were taped apart and she was prepped by the clock for 15 minutes. She was then draped in a sterile fashion, 1% lidocaine was injected, 9 cm up from the tip of the coccyx, 2 cm out, and 2 cm up, using a C-arm that was draped under fluoroscopic guidance the 3.5 inch needle was inserted into the left S3 foramen and under fluoroscopic guidance was advanced to the level of the posterior table of the sacrum, but not through it. Once there, it was tested, there was good bellows and good big toe response and so the stylet was placed through this. A small incision was made, the dilator was inserted and again care was taken not to perforate the posterior table.
The dilator was advanced to the level just flush to the posterior table. The introducer was removed from the dilator and the electrode was inserted. __________ three of the electrodes visible beneath the sacrum. They were then tested again. There was good bellows and good plantar flexion of the great toe. Using local, further incision was made over the right iliac crest lateral to the sacrum Blunt dissection was used until the gluteal fascia was identified. Hemostasis was controlled. The pocket was irrigated with gentamicin solution using the tunnelling tool starting from the insertion site to the pocket, first injecting subcutaneously the tunnelling tool was passed and the lead was passed into the pocket. The neurostimulator was then attached. Once the metal lines were aligned the blue leads were clearly visible in the distal portion, single setscrew was tight. The nerve stimulator was then programed to pulse width of 210, rate of 14 that was tested, impedances were confirmed to be within normal limits greater than 50 and less then 4000. The wound was irrigated with gentamicin solution. The subcuticular flap was closed with 4-0 chromic sutures. The skin was closed with 4-0 Monocryl subcuticular. The smaller incision was Dermabonded shut and the larger incision Steri-Stripped, covered with a sterile dressing. The patient was flipped supine and taken to the recovery room in good condition.
Thanks