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