You have requested access to member-only content.

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.

 

 

This is an excerpt from member-only content. Please log in or become a member.

Not a member? Let's fix that!

JustCoding is the continuing education website for coding professionals. Whether you're an inpatient or outpatient coder, a veteran or new to the job, JustCoding will keep your skills sharp, test your coding knowledge, and help you stay abreast of CMS changes.

Register to access the free content available through the JustCoding site or subscribe to a Basic or Platinum membership to access paid content on this site. Click here for more information.

For questions and support, please call customer service: 800-650-6787.