AHA Coding Clinic® for HCPCS - 2023 Issue 3; Ask the Editor

Leadless posterior tibial nerve stimulator implantation

A patient with urge urinary incontinence presented for the insertion of a leadless posterior tibial nerve stimulator. The left leg was positioned and marked near the medial malleolus for device implantation. An incision was made with a 15 blade approximately 3 cm in length, and the area was bluntly dissected to the level of the fascia. Care was taken as not to penetrate the fascia. The pocket was created using the custom pocket creation tool; care was taken to prevent over dissection. Then, the leadless tibial nerve stimulator system was placed into the pocket. A suture was placed at the superficial distal fascia to close the pocket. The incision was closed in three meticulous layers with buried subcutaneous fat sutures, deep dermis sutures and sutures in the subcuticular layer. Derma-bond was applied on top. The patient tolerated the procedure well.How should the implantation of the leadless posterior tibial nerve stimulator system be reported? ...

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