Part 10: Spinal Fusion Coding — Removing Hardware from Previous Fusion

by Sep 30, 2019Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding0 comments

Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.

Coders should be able to determine if a previous fusion has been performed based on the documentation within the patient’s record. Diagnoses to look for would be nonunion, psuedoarthrosis and/or failed fusion to name the most common.

Is removal of hardware from a previous fusion coded or is it included in the new fusion/re-fusion code?

YES! Removal of hardware from a previous spinal fusion would be coded in addition to the new fusion (if performed) at the same level. The new fusion codes will include any hardware that will be placed and no additional code would be reported. Removing of previous hardware has a separate objective than any refusion that may be considered. If hardware is removed from more than one level, each should be coded (i.e. thoracic, and lumbar).

Some statements to look for in the operative note to see if any hardware is removed would be removal of pedicle screws/rods and/or removal of previous interbody fusion device.

View parts 1-9 of this series here: hiacode.com/topics/series/spinal-fusion-coding/.

Be on the lookout for Part 11 which will discuss computer assisted navigation.

Coding Clinic, Third Quarter 2014: Page 30

Happy Coding!

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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