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AHA Coding Clinic® for HCPCS - 2021 Issue 1; For Your Information

Removal and insertion of a sacral neurostimulator generator system

Patient with a previous left sacral InterStim™ system was experiencing malfunction and migration of the lead, urinary incontinence, and pain. A decision was made to remove the left sacral neurostimulator system and insert a right sacral neurostimulator system. An incision was carried down to capsule on the left side where the lead was cut and the generator removed. A stab incision was made and the lead was removed. On the right side, an incision was made for the percutaneous transforaminal placement of the neurostimulator lead with three electrodes. Under fluoroscopic guidance, the lead was guided through the introducer sheath until the electrodes were visible below the sacrum. The gluteal fascia was dissected creating a subcutaneous pocket for the neurostimulator. The lead was fed through the tunneling tool and pulled into the pocket where the neurostimulator was placed and the leads were connected. Is it appropriate to report the removal of the previously placed sacral neurostimulator system from the left side in addition to insertion of a new system (generator and leads) on the right side? ...

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