Billing and Coding: Spinal Fusion Services: Documentation Requirements

Noridian Medical Review team and CERT contractor has identified multiple errors regarding documentation to support the medical necessity of spinal fusion procedures. This article clarifies medical necessity and documentation requirements regarding spinal fusion procedures. Medical Necessity History and Physical Duration/character/location/radiation of pain Activity of daily living (ADL) limitations Physical examination Evidence/support of prior conservative treatment measure(s) attempted* Imaging reports pertinent to performed procedure Operative report(s) Outpatient records before, during and after the procedure that support the medical necessity of performed procedures *Note: physician statement that conservative treatment measures were completed is not supportive in and by itself; contractors do require the documentation of these measures. Documentation Errors The most common reason for denial of spinal fusion services is lack of specific information regarding conservative treatment measures which were attempted and failed prior to surgery. The statement "failed conservative/outpatient treatment" is not sufficient evidence of medical necessity for the procedure or inpatient admission. A detailed medical record will help to support the reasonableness of the claim. Conservative treatment modalities include but are not limited to: Physical Therapy Occupational Therapy Joint Injections/Epidural Injections Anti-inflammatory/Analgesic medications Assistive device use Activity modification Exercise Situations arise where a fusion is approved without conservative treatment being documented clearly when an emergent situation such as "cauda equina syndrome" is present. Also if an imaging report showing severe cord compression, osteophyte formation impinging on the spinal cord, loose pedicle screws affecting stability, severe fibrosis or formation of scar tissue compressing cord or nerves, and the patient's history and physical findings correlate to the imaging the surgeon should clearly document these findings and the reasons that such findings require imminent intervention.