The original generator moves to another pocket

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-09-09 · Professional operative service; cited Medicare NCCI relationship

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Device concern

Synthetic adult with a functioning spinal neurostimulator reports persistent discomfort over the right upper-buttock generator pocket. The surgeon plans pocket relocation. No generator malfunction, lead revision or electrode-array replacement is documented.

Operative sequence

The surgeon opens the right upper-buttock pocket, temporarily disconnects the existing generator, prepares a new pocket lower on the same side and transfers the original generator into it. The existing leads are reconnected without revision. Inventory and device identifiers confirm that no new generator is implanted.

Identity check

The device identifier before and after the operation is unchanged. The report’s words removal and insertion refer to handling and relocating the original device. They do not establish a replacement generator simply because the pocket location changes.

Charge review

The draft selects the new-generator replacement pathway and adds a removal line. Compare that proposal with NCCI’s distinction between revision or relocation and replacement. The learner must use the original device’s identity, the actual work and the current complete entry.

Your coding worksheet

Identify the device that remains after surgery.
Determine whether a new generator is documented.
Choose the relationship to investigate before exact coding.
Evaluate the proposed replacement and extra removal.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Compare with the worked explanation

The original generator remains in use in a different pocket.
No new generator is implanted.
NCCI C.16 directs review of the revision relationship rather than the replacement pathway requiring a new device.
The two verbs do not justify the proposed replacement plus removal; review the full entry for the actual relocation work.

Reference sections: C.16

Practice the linked chart questions