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.
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.
Learn more about Spinal Fusion Coding by purchasing our Spinal Fusion Coding eBook.
Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P
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.