Part 2: Spinal Fusion Coding — Initial Fusion or Refusion

by | Sep 11, 2019 | Coding Tips, Education, ICD-10, Kim Carrier, Spinal Fusion Coding | 0 comments

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

In Part 1 we discussed the diagnoses typically responsible for a patient requiring a spinal fusion. In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.” The definition in ICD-10-PCS for fusion is “joining together portions of an articular body part rendering the articular body part immobile.” For spinal fusions, this means that two or more vertebrae are joined together and this prevents movement between the fused vertebrae.

Although, in ICD-10-PCS, the fusion and refusion are both coded to the same root operation of fusion, coders still need to know which the surgeon is performing. This will also alert the coder to look for additional procedures that may need to be captured in the operative note documentation (such as a removal of previous device).

Initial Spinal Fusion:

This is the first time a fusion is being performed on a specific vertebrae. The patient could have had a past fusion at a different level, but it is determined based on the level that is being fused and not the past history. In the same operative note, there may be documentation of an initial level of fusion as well as another level that may have required a refusion. Here are the most common reason an initial spinal fusion may be needed:

  • Degenerative disc disease/disc degeneration
  • Spinal stenosis/neurogenic claudication
  • Spondylolisthesis
  • Herniated disc/slipped disc/ruptured disc
  • Scoliosis/lordosis/kyphosis
  • Radiculopathy/pinched spinal nerve
  • Myelopathy

Refusion of Spine:

This is when a patient has already had a spinal fusion at one level and now requires fusion again on that specific vertebrae. As above, the operative note should be read carefully to be sure that there aren’t additional “initial” fusions being performed at the same time. This may change the number of joints reported or other ICD-10-PCS code characters. Here are the most common reasons a refusion of the spine may be needed:

  • Pseudoarthrosis/non-union/failed fusion
  • Injury resulting in damage to the initial fusion
  • Complications of the initial area fused

Spinal fusions are performed to permanently connect two or more vertebrae in the spine that eliminates motion between them. The fusion/refusion will mimic the normal healing process of a broken bone by the use of bone or bonelike material between two spinal vertebrae. Oftentimes, it takes months for the spinal vertebrae to heal and fuse together. A successful fusion or refusion would be defined as; when the vertebrae that were fused together heal into a single solid bone. There is no time limit on when a fusion may be considered a failed fusion/non-union.

Click here to read Part 1: Spinal Fusion Coding — Diagnoses Responsible.

Be on the lookout for Part 3, that will discuss how to determine the level(s) of a fusion as well as number of vertebrae being fused together.

References
https://www.spine-health.com/treatment/spinal-fusion/diagnostic-studies-patient-history-and-physical-exams-spinal-fusion
https://www.spine-health.com/treatment/spinal-fusion/spine-fusion-indications
https://www.orthoinfo.aaos.org/en/treatment/spinal-fusion
https://www.orthoinfo.aaos.org/en/treatment/spinal-fusion-glossary
https://www.mayoclinic.org/tests-procedures/spinal-fusion/about/pac-20384523
https://www.beckerspine.com/spine/item/35441
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2019

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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