Removing Hardware from Previous Fusion | Spinal Fusion Series

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 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.

 

Download Spinal Fusion Series eBook.

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

References
spineuniverse.com/treatments/surgery/spinal-fusion-instrumentation-removal-pros-cons
nuffieldhealth.com/treatments/removal-of-spinal-hardware
https://consultqd.clevelandclinic.org/?s=interbody+device 
Coding Clinic, Third Quarter 2014: Page 30

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.

Leave a Comment

    Category

    Related blogs from Medical Coding Tips

    List of New ICD-10-PCS Codes

    In this Coding Tip, we present the new ICD-10...

    List of New ICD-10-CM Codes

    The CDC has published new codes that will be ...

    List of New C Codes for ASC Reporting

    On December 21, CMS released the following Tr...