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Q&A: Interpreting incomplete fusion documentation
Q: I am auditing a note for a fusion. The note lacks detail, therefore is hard to justify. The patient had a prior hardware placement. The note describes dissecting down, debridement of necrotic bone, and tissue work done. This is the entire note, after describing dissection, “Vigorous irrigation with 10 liters of saline and antibiotics was carried out. Hemostasis was maintained. The right S1 screw and rod portion was removed as it was notably loose. Additional decortication and onlay bone grafting was performed at L1-S1. Drains were placed…”
They coded:
- 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar)
- Add-on code 22614 (each additional vertebral segment) x4
- 22852 (removal of posterior segmental instrumentation)
In the procedures performed area of the note, they state:
- Hardware removal, lumbar
- Revision fusion L1-S1 with onlay bone graft
- Irrigation and debridement of lumbar spine wound
Since there is nothing in the note regarding autografting, I assume this is an allograft? Should this be coded? Also is that documentation enough to justify arthrodesis?
Modifier -GC (this service has been performed in part by a resident under the direction of a teaching physician) was appended, although the language was not added for this. I can only assume a resident dictated this.
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