Spinal Fusion Coding: Region of Fusion and Number of Vertebrae Fused

Level(s) of the spinal column and number being fused

As you can see in the picture below, the human vertebral column consists of 33 vertebrae divided into five regions:

• Cervical—7
• Thoracic—12
• Lumbar—5
• Sacrum—5 (sometimes 6)
• Coccyx—4

Photo Courtesy: wikimedia.org

When reviewing the operative note, look for what level(s) are being fused together. A level involves two vertebrae and the space between them (interspace) containing the disc. In ICD-10-PCS, two adjacent vertebrae separated by an interspace (level) is call a vertebral joint.

How to report multiple levels?

When the surgeon documents that a fusion consisted of only two vertebrae, and they are of the same level (such as lumbar) then this is counted as only one level. However, in the same procedure if the surgeon also performs a fusion of another level (such as sacrum), this part of the fusion would also need to be reported.

Coding Examples

To view coding examples, purchase our Spinal Fusion Coding eBook.