Billing Worksheet
Patient Name:______________________________________________________ Implant Billing Worksheet Physician Name:_______________________________________________________ SPINAL CORD STIMULATION Date:________________________________ Time:_______________________ £ Trial £ Implant Lead Location:_________________________ Payer:_______________________ Site of Service:___________________________ Physician Signature:______________________________________________ CPT 63650: Percutaneous implantation of neurostimulator electrode array, epidural Percutaneous Leads Trial Leads CPT 63650, 1 unit per lead (list number of leads and lead length below) 1×8 Subcompact C-code: C1778 __ 3776-____ 1×8 Standard 1×8 Compact __ 3777-____ __ 3778-____ Pisces™ Standard C-code: C1897 L-code: L8680 Pisces Compact __ 3487A-____ __ 3887-____ Pisces Plus 1×8 Standard 1×8 Compact __ 3888-____ __ 3873-____ __ 3874-____ 1×8 Subcompact # of leads ________ __ 3875-____ L-code: L8680 # electrodes ________ CPT 63655: Laminectomy for implantation of neurostimulator electrodes, epidural Surgical Leads 63655, 1 unit per lead (list number of leads and lead length below) C-code: C1778 Specify™ 5-6-5 Specify™ 2×8 Specify™ 2×4 Hinged Resume II® Resume® TL ___ 39565-____ ___ 39286-____ ___ 3998-____ ___ 3999-____ ___ 3587A-____ ___ 3986A-____ # of leads _________ L-code: L8680 # electrodes _________ Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Medtronic has compiled this coding information for your convenience. It is always the provider’s responsibility to determine coverage and submit appropriate codes, modifiers, and charges for the services that were rendered. Please contact your local MAC/payer for interpretation of appropriate coverage and coding policies. CPT 63685: Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Neurostimulators Rechargeable Neurostimulator RestoreUltra® L-code: L8687 Patient Programmers C-code: C1820 L-code: L8689 ____ 37711 Nonrechargeable Neurostimulator Synergy® L-code: L8688 ____ 7427 Synergy Versitrel® ____ 7427V-NP L-code: L8688 Itrel® 3 L-code: L8686 C-code: C1767 ____ 7425 1x8 Extension ____ 37081-____ MyStim® Synergy® EZ £ £ £ £ 3550-31 Snap-lid connector cable 3550-39 Titan anchor 3550-28 Epidural needle 3550-14ACurved-tip needle 3550-29 Plug and boot 3550-02 Wrenches and screws Antenna: Other: £ £ £ £ £ £ ____ 37752 ____ 7435 Itrel® EZ ____ 7434A 3550-24 Boot and anchor kit 3550-16 EZ anchor 3655-38 1×8 tunneling tool 3550-27 1×8 lead revision kit 3550-43 Curved-tip needle Synergy Extension Bifurcated Stretch-Coil™ ____ 7472-____ ____ 37082-____ Pocket Adapter Single Stretch-Coil™ ____ 74001 ____ 37083-____ ____ 74002 Other Procedures: £ 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver £ 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed £ 63662 Removal of spinal neurostimulator electrode plate/paddle, including fluoroscopy when performed £ 63663 Revision, including replacement when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy when performed £ 63664Revision, including replacement when performed, of spinal neurostimulator electrode plate/paddle(s), including fluoroscopy when performed £ 95972 Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance, and patient compliance measurements), complex spinal cord or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour 3550-05Percutaneous extension (in-line connector for quadripolar leads only) ____ 7489-____ (8-contact in-line connector) ____ 37743 Common Accessories (not all listed) £ £ £ £ C-code: C1883 (with in-line connector) External patient recharger system PrimeAdvanced® ____ 37702 L-code: L8688 Extensions and Adaptors # of extensions________ Low-profile Quad ____ 37712 RestoreAdvanced®____ 37713 L-code: L8687 Restore® L-code: L8687 Recharger C-code: C1787 L-code: L8681 Notes: Note: Definition of L8681 and L8689 are for replacement only. Do not bill these codes when providing the initial external recharger or the initial patient programmer. UC200905843b EN NI9874b © 2011 Medtronic, Inc. Printed in USA. Product
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