Removing Hardware from Previous Fusion | Spinal Fusion Coding Series

In our blog post, Was A Decompression Done During Spinal Fusion?, we focused on identifying if decompression was also performed and if so, on which body part. In our other blog post, Removing Hardware from Previous Fusion, we focused 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.

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


    Related blogs from Medical Coding Tips

    Nov 27, 2023

    Key Quality Measures in Healthcare: Mortality and ...

    In the healthcare industry, quality measures ...

    Coding and Reporting Personal and Family History i...

    As a coder, you may wonder why it is so impor...

    Excision vs. Resection ICD-10-PCS

    The focus of this coding tip is on the excisi...

    Procedures Performed Via Burr Hole

    With the implementation of ICD-10-PCS came mo...