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

This blog post focuses on determining the level(s) of fusion, as well as the 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

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.

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

References
https://commons.wikimedia.org/wiki/File:Figure_38_01_07.jpg
https://www.spine.org/KnowYourBack/Treatments/Surgical-Options/Spinal-Fusion
https://idataresearch.com/how-many-instrumented-spinal-fusions-are-performed-each-year-in-the-united-states/

ICD-10-CM/PCS Coding Clinic, Third Quarter 2019 Pages: 35-36
ICD-10-CM/PCS Coding Clinic, Fourth Quarter 2021 Page: 67
ICD-10-CM/PCS Coding Clinic, Second Quarter 2021 Pages: 23-24
ICD-10-PCS Official Guidelines for Coding and Reporting FY 2023

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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