Reader Questions: Report Both Lead, Generator Removal- Published on Fri, Mar 31, 2006
Question: What code should I use for the removal of interstim?
Answer: If your urologist removed just the lead, you should report 64585 (Revision or removal of peripheral neurostimulator electrodes). If he also removed a generator, you should report 64595 (Revision or removal of peripheral neurostimulator pulse generator or receiver) as well.
Example: A patient presents with urinary retention (788.20) and the urologist evaluates her, determining that she is a prime candidate for sacral nerve stimulation. But after the physician implants the lead and generator, one of the two components malfunctions.
To code the removal of the permanent lead, report 64585, and if the urologist also has to remove the generator, use 64595. The applicable diagnosis code in this case is 996.75 (Other complications of internal [biological] [synthetic] prosthetic device, implant, and graft; due to nervous system device, implant, and graft).
Note: If the patient is still in a 90-day global period from the initial insertion, you may need to append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to the procedure code.