Spinal Fusion Code Cautions

Spinal Fusion coding can be an area of apprehension for a lot of coders! Coding opportunities sometimes are buried within the body of operative reports which makes it even more challenging. First and foremost, be sure to read the entire report to capture all pertinent codes.

Consider the following snippet, which comes from an actual operative report and supports the assignment of 0SG0071 (fusion of lumbar vertebral joint with autologous tissue substitute, posterior approach, posterior column, open approach):

“I then loaded the tulip-heads onto the screw shanks, and I then placed a Creo addition titanium rod. Posterior instrumentation replaced from the L3-4 interspace modular loading cross connector to L1 pedicle screw. I contoured lordosis in the back table before placement into the Tulip head. Final tightened compressed at L1-2. I used a high-speed bur to decorticate the facet on the left side at L1-2, and the transverse process bilaterally of L1-L2 and placed local bone and osteosurge to complete a posterolateral fusion.”