Superseded Local Coverage Article

Spinal Fusion Services: Documentation Requirements

A53972

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Superseded
To see the currently-in-effect version of this document, go to the section.

Contractor Information

Article Information

General Information

Article ID
A53972
Original ICD-9 Article ID
A53966
Article Title
Spinal Fusion Services: Documentation Requirements
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
04/12/2018
Revision Ending Date
N/A
Retirement Date
N/A
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Article Guidance

Article Text

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.

Coding Information

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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CPT/HCPCS Codes

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ICD-10-CM Codes that are Covered

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ICD-10-CM Codes that are Not Covered

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
04/12/2018 R1

This article, effective 4/12/2018, combines JEA A53971 in JEB A53972 so that both JEA and JEB Contract numbers will have the same final MCD Article number A53972.

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
09/29/2020 04/12/2018 - N/A Currently in Effect View
04/03/2018 04/12/2018 - N/A Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Spinal
  • Fusion
  • Documentation
  • Errors
  • Medical Necessity
  • Conservative
  • Treatment