Sample Coded report for Spinal Cord Stimulator Battery Replacement Exam

Pre-op Diagnosis: Chronic pain syndrome [G89.4]

Mechanical breakdown of implanted electronic neurostimulator of spinal cord, initial encounter (CMS/HCC) [T85.112A]   

Post-op Diagnosis: Same as Pre-op

Procedure(s): Spinal Cord Stimulator Battery Replacement – Wound Class: Clean

Anesthesia: Monitor Anesthesia Care

Estimated Blood Loss: None

Drain:  None 

 Total IV Fluids:  Per anesthesia record  

Specimens: No specimens

Complications:  None

Findings:  None     

Disposition: aroused from sedation, and taken to the recovery room in a stable condition    

Condition: doing well without problems

Technique:  The patient was placed prone on the operating room table, with monitored anesthesia care.  Lumbar region sterilely prepared and draped in usual fashion.  Local anesthetic over the existing IPG.  Transverse incision made.  IPG removed, disconnected.  New IPG connected.  Impedances equivalent to impedances with the old IPG.  IPG secured in the pocket after meticulous hemostasis, copious antibiotic irrigation, and vancomycin powder placed in site.  Dry sterile dressing

CPT code:

63685 INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER 

The provider inserts or replaces a spinal neurostimulator pulse generator or receiver. The system is one that requires surgical creation of a pocket for placement and that requires a connection between the electrode array and the pulse generator or receiver.

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