Wiki Is 64585 appropriate for removal and replacement?

kkidd91

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I think that only CPT 64585 should be billed for the following procedure based on NCCI edits. Even though 64555 has a higher RVU it hits an edit with 64585. Please advise if you would bill 64555 as well with an XS modifier. This is the first time we have seen a revision of a peripheral neurostimulator at our ASC. I appreciate any guidance you can offer.

POSTOPERATIVE DIAGNOSES: 1. Broken right superomedial genicular nerve peripheral neurostimulator lead.2. Right superomedial genicular nerve mononeuropathy.

OPERATIONS PERFORMED: 1. Revision right superomedial genicular nerve peripheral neurostimulator lead. 2. Implantation of peripheral neurostimulator lead, right superomedial genicular nerve.

Given his medical background and potential for longer procedure, a short-acting spinal was placed. The operative time-out was performed with all members of the operating room staff confirming patient, procedure, side, and site. Preoperative antibiotics were administered. The transverse incision was made over the initial insertion site about 10-15 cm proximal to the joint line where the cord leads could be identified. I was able to identify by x-ray the lead that was heading down towards the superomedial genicular nerve and pulled that out through that incision from distal to proximal. A second incision was then made directly over the "arms" of the IPG taking care not to damage the insulation themselves and maintaining the subcutaneous pocket. The medial arm was verified to correspond to the broken lead by a gentle tug, and it was unscrewed and removed. Of course prior to this, we verified functioning of the lateral lead and malfunction of the medial as well. At this point, we verified that the lateral lead was still functioning. A distal incision was made directly over the medial epicondyle, and using a combination of palpation and fluoroscopy, I was able to isolate the distal tip of the broken medial lead. It was grabbed with a tonsil and removed in an antegrade fashion so as not to disrupt the tissues at all times with times. At this point, a new needle/trocar was used from the middle incision to the medial epicondyle, verified in position to correlate with standard positioning and the prior position of the previously successful lead and a new 40-cm tined lead was inserted through the trocar with good fixation, and the trocar of course was removed. I tunneled the proximal aspect of the lead up to the IPG arm and plugged it in and verified that this new medial lead was now functioning and torqued it into position. The final check of the entirety of the functioning device was performed and successful. At this point, all 3 incisions were thoroughly irrigated and closed carefully with buried and subcuticular suture, and sterile dressings were placed. The patient was awakened from anesthesia and brought to the recovery room in stable condition and without complication
 
New to ortho, so don't let me be your last decision, but researching this, agreed. CPT 64585 includes both removal and replacement of peripheral leads when part of revision of an existing system.
Happy to learn otherwise.
 
Can anyone direct me to who I might be able to contact at AAPC or AAOS for further clarification or documentation? (I am not a member of AAOS) and I am struggling to understand the reasoning why I have been advised to use 64555 over 64585. I am new to these types of procedures and am trying my best to fully understand.

I have been advised, “If it is traditional Medicare, it should be billed as if it was a new implant. Instead of 64585, 64555 should be billed. This will cover the cost of the replacement device. And “both 63650 and 64555 are almost identical codes. They were created as mirrors. The rule has always been that when a revision converts to a replacement, the revision code can no longer be billed, and the insertion code is billable to allow the devices replaced to be reimbursed. For spinal cord stim, the revision code specifically states that replacement is included in 63663, whereas for peripheral nerve stim, it is not included in 64585.”

I questioned and asked

“How it is appropriate to unbundle and only bill 64555 since 64555 is included in 64585 based on NCCI edits? I can’t ignore that a removal was completed (64585) and when running codes 64555 & 64585 together through our clear claim connection it states 64555 is not recommended for separate reimbursement”

The response received was “It is not considered unbundling, but rather an either/or situation. More than 50% of revision cases convert to replacement due to devices breaking or the physician determining that they are not functioning once the procedure begins. If it remains a revision procedure and no devices are “swapped out”, then 64585 is appropriate. If devices are replaced, 64555 is billed in place of 64585. Medicare will not allow payment for both codes, but they will allow payment that provides appropriate reimbursement for the implantation of the new device”

I appreciate any additional advice you may be able to offer as I have read through the official CPT Assistant source for CPT coding and guidance on new and revised neurostimulator codes and still cannot locate any specific documentation that allows CPT 64555 to be billed over 64585. Our administrative department is involved, and I am trying to justify my reasoning for only selecting 64585.

https://www.ama-assn.org/system/files/cpt-assistant-neurostimulator-codes.pdf
 
First of all, this is not an Ortho issue - this is done by PM&R or Anaesthesiology-trained Interventional Pain Mgmt docs almost exclusively, and to a much lesser extent by spine surgeons. AAOS is not at all who you want to ask.

Secondly, a single lead was replaced. The whole device was not. This is 64585. There is no reasonable argument for 64555 based on that op note.
 
I am reading more and more on this and I can see that I am wrong and that an argument -could- be made for 64555.

The other related family codes lump "insertion or replacement" and "revision or removal" together, though the specific codes 64555 and 64585 do not. I do not have access to the CPT notes and the codes were not surveyed and so no vignettes exist. So either it was a purposeful omission and I'm right, or one can extrapolate from the other codes and I'm wrong.

Throughout Orthopaedics and the related sections of CPT, the word "revision" refers to removal AND replacement of a component, not merely repositioning. The argument here is that, unlike the rest of ortho, in the field of Neurostimulation, "revision" means only repositioning but not replacement. I don't see any reason for this to be the case. However, a review of RUC Physician Expense inputs for 64555 includes the cost of the implant whereas those for 64585 do not (these data are also available within the CMS PFS dataset and are all publically available). This suggests that 64585 was not intended to include any component replacement.

I will admit that this could go either way and that I can find zero legitimate guidance that would or could carry any weight beyond the no facility PE inputs, which are apocryphal at best, but suggest to me that 64555 is the correct code here.

So. With no better guidance, I would support your surgeon with the more appropriate reimbursement for the implant costs. I am sorry that I seemingly led you astray above!
 
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