DRG 460 - Spinal Fusion

Published 06/13/2019

Spinal fusion is a surgical procedure used to correct problems with the small bones in the spine, called vertebrae. It is essentially a "welding" process, the basic idea being to fuse together the affected pain-causing vertebrae so that they heal into a single, solid bone.

The following strategies could reduce audit errors caused solely by information missing from the hospital record:

  • Hospitals may proactively obtain previous diagnostic and therapeutic records from the surgeon and other practitioners. These records may include pertinent:
    • Physical assessment of condition, including pain level
    • Physician history and physical exam
    • Progress notes
  • Consultations
  • Physical and occupational therapist evaluations and therapy notes
  • Radiology reports
  • Therapeutic procedure notes, such as joint injections

Practitioners should either create clinically meaningful inpatient records or supply the hospital with relevant documents from their outpatient records. This list contains examples of documentation that, if clearly documented, may help support payment for spinal fusion-related hospital care.

  • Previous non-surgical treatment, including, but not limited to: 
    • Physical therapy
    • Occupational therapy
    • Joint injections
    • Analgesics
    • Assistive devices
  • Physical examination clearly documenting the progression of any:
    • Neurological deficits
    • Upper or lower extremity strength
    • Activity modification
    • Pain level
    • Diagnostic test results and interpretations, such as MRI
  • Neurological deficits
  • Upper or lower extremity strength
  • Activity modification
  • Pain levels

Documentation should tell a good story that anyone can understand substantiating the medical necessity of the procedure for that particular patient.

By far the most common reason for denial has been a lack of specific information about conservative care before the surgical intervention. Statements such as: “Failed outpatient therapy, admit for spinal fusion” are simply not sufficient evidence of medical necessity for the admission or the surgery.

Documentation should include:

  • History of illness from onset to decision for surgery
  • Prior courses of treatment and results
  • Current symptoms and functional limitations
  • Physical exam detailing objective findings supporting history of illness
  • Results of special tests