Problem:
Assign the appropriate CPT code(s) for each of the cases. Assign only anatomic modifiers (such as LT, RT, E1) and modifier 59 if appropriate. Do not append modifier 51. If you wish to practice assigning codes by body system, the following reference will help. Operative Report Preoperative Diagnosis: Neurogenic bladder with an implanted sacral nerve stimulator Postoperative Diagnosis: Neurogenic bladder with an implanted sacral nerve stimulator Procedure Performed: Removal of InterStim sacral nerve stimulator Indications for Procedure: This patient is a 96-year-old female with a history of neurogenic bladder with recurrent urinary tract infections due to poor emptying. She is here for removal of her sacral nerve stimulator, which had subsequently quit working. After all the risks, benefits, and expected outcomes were explained, she agreed to proceed. Details of Procedure: The patient was brought to the operative suite, given a light intravenous anesthetic, and laid in the prone position. The area overlying the InterStim neurostimulator was infiltrated using 1% lidocaine mixed with 0.35% Marcaine. Once this was done, an incision was made over this and dissection was carried down to the InterStim neurostimulator. The device was removed from its pouch. The leads, which were tunneled down to the S3 foramina