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AHA Coding Clinic® for HCPCS - 2022 Issue 4; Ask the Editor

Epidural spinal cord stimulator insertion

A patient with intractable chronic low back pain presented for placement of a permanent spinal cord stimulator. After prone positioning, a Tuohy needle was advanced into the epidural space. The spinal cord neurostimulator electrode array was advanced through the needle and directed to rest the tip as determined by mapping. The same procedure was repeated on the right side inserting a second electrode array within the epidural space to reside just inferior to the previous lead. A receiver was inserted in both electrode arrays thereby making both leads a neurostimulator. Once the stimulators were assured to be sufficient per the patient, the needles were left in place and 3-4 cm incision was made below both needles. A pocket was then undermined and made at this location for the receiver. The leads were anchored, and the stimulators were measured for tunneling and tunneled to the receiver pocket. Blunt dissection was done to ensure full thickness was obtained. The Tuohy needle was inserted distally to proximally and the stimulator was fed through the needle, identified distally, and pulled through. A knot and coil were made. The procedure was repeated for the other side. The coil was then secured in the receiver pocket. All wounds were closed in a layered fashion after irrigation with 3.0 Vicryl. Which CPT codes are reported for the neurostimulator insertion in this case? ...

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