Billing and Coding: Spinal Fusion Services: Documentation Requirements

Spinal fusion claims require detailed documentation including H&P (pain characteristics and ADL impact), physical exam, imaging reports, operative and outpatient records, and objective records of prior conservative treatments; a physician's statement alone that conservative therapy 'failed' is insufficient. Exceptions permitting immediate surgery without documented conservative care include emergent conditions (e.g., cauda equina syndrome) or clearly documented severe imaging findings with correlated exam demonstrating need for imminent intervention.

"Spinal fusion is supported when the medical record documents specific conservative treatment measures were attempted and failed, with details of modalities, duration, and reason for failure."

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