How To Use CPT Code 64581

CPT 64581 describes the open implantation of a neurostimulator electrode array in the sacral nerve using a transforaminal placement. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 64581?

CPT 64581 can be used to describe the open implantation of a neurostimulator electrode array in the sacral nerve. This procedure involves making an incision in the lower back to access the target location and placing the electrode array through the foramen of the sacral nerves. It is commonly performed to treat conditions such as urinary or fecal incontinence or chronic pelvic pain.

2. Official Description

The official description of CPT code 64581 is: ‘Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made in the lower back to access the target location.
3. The provider identifies the root of the sacral nerve or nerves.
4. The neurostimulator electrode array is placed through the foramen of the sacral nerves.
5. If a pulse generator is present, the provider may connect the array to it and test for correct placement or function.
6. The provider closes the incision.

4. Qualifying circumstances

CPT 64581 is performed on patients who require an open implantation of a neurostimulator electrode array in the sacral nerve. This procedure is typically indicated for conditions such as urinary or fecal incontinence or chronic pelvic pain. The patient must meet the criteria for this specific treatment, and the provider must determine that the procedure is medically necessary.

5. When to use CPT code 64581

CPT code 64581 should be used when an open implantation of a neurostimulator electrode array in the sacral nerve is performed. It is important to ensure that the procedure meets the specific requirements outlined in the code description. If the procedure does not involve the sacral nerve or does not use a transforaminal placement, a different code should be used.

6. Documentation requirements

To support a claim for CPT 64581, the provider must document the following information:

• Reason for the procedure and the patient’s condition
• Details of the procedure, including the incision, placement of the electrode array, and any testing performed
• Date of the procedure
• Any complications or unexpected findings
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 64581, ensure that the procedure meets the specific requirements outlined in the code description. It is important to accurately document the details of the procedure and any necessary supporting documentation. Be aware of any additional guidelines or modifiers that may be required for proper billing.

8. Historical information

CPT 64581 was added to the Current Procedural Terminology system on January 1, 2002. There have been changes to the code description over the years, with the most recent change occurring on January 1, 2022.

9. Examples

1. A patient with urinary incontinence undergoes an open implantation of a neurostimulator electrode array in the sacral nerve to improve bladder control.
2. A patient with chronic pelvic pain receives an open implantation of a neurostimulator electrode array in the sacral nerve to alleviate their symptoms.
3. A provider performs an open implantation of a neurostimulator electrode array in the sacral nerve for a patient with fecal incontinence to improve bowel control.
4. An individual with refractory overactive bladder undergoes an open implantation of a neurostimulator electrode array in the sacral nerve to manage their symptoms.
5. A patient with interstitial cystitis receives an open implantation of a neurostimulator electrode array in the sacral nerve to alleviate their pain and discomfort.
6. A provider performs an open implantation of a neurostimulator electrode array in the sacral nerve for a patient with chronic constipation to improve bowel function.
7. An individual with chronic pelvic pain undergoes an open implantation of a neurostimulator electrode array in the sacral nerve to manage their pain and improve their quality of life.
8. A patient with neurogenic bladder receives an open implantation of a neurostimulator electrode array in the sacral nerve to improve bladder function and control.
9. An individual with pudendal neuralgia undergoes an open implantation of a neurostimulator electrode array in the sacral nerve to alleviate their pain and discomfort.
10. A provider performs an open implantation of a neurostimulator electrode array in the sacral nerve for a patient with chronic prostatitis to manage their symptoms and improve their quality of life.