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AHA Coding Clinic® for HCPCS - 2011 Issue 3; ASK the EDITOR

Aborted placement of neurostimulator leads

A patient was seen at our facility for the removal of an old dorsal column stimulator and replacement of a new stimulation system. According to the operative report, both the generator and the electrodes were successfully removed, but since the new leads could not be placed, the procedure was aborted without any new devices being implanted. We are familiar with the guidelines for reporting the intended procedure with modifier 73/74 for incomplete procedures, but in this case, with separate procedures for implant/removal/replacement, it’s a bit more challenging! Would it be appropriate to report both of the intended procedure(s) with modifier 74, (63685-74, 63663-74) or to report the spinal stimulator replacement code, 63685, with modifier 74 along with the code for the successful electrode removal (63661), or whether to report the removal of the generator (63688), plus the intended electrode replacement (63663-74), or some other combination of codes. There is another option to consider which would be to report both of the removal codes, 63688 and 63661. ...

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