tci Outpatient Facility Coding Alert - 2018 Issue 8

Reader Question: Use M43 Code Set to Report Congenital Spinal Fusion

Question: I’ve come across a report that states that the L5-S1 spine has fused together. I do not see any reference to a previous fusion surgery. How should I code this diagnosis? Indiana Subscriber Answer: As long as the report does not reference a prior arthrodesis procedure, then you may consider the L5-S1 fusion to be congenital. You may then refer to code M43.27 (Fusion of spine, lumbosacral region) as the only code necessary to report the diagnosis. However, keep in mind that depending on the reason for the scan, congenital fusion may not be a relevant...

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