Spinal Fusion Coding: Removing Hardware from Previous Fusion

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 with rods and/or removal of previous interbody fusion device. Screws are put into vertebral bone so if they are removed it is coded as removal.

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