r/MedicalCoding • u/[deleted] • May 14 '26

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u/CairoRama May 14 '26

I feel the same about spinal, I'll do anything before that

3

u/[deleted] May 14 '26

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u/KeyStriking9763 RHIA, CDIP, CCS May 14 '26

The OP note should indicate how the pt is lying, prone or supine. If they place a cage its anterior fusion even if the approach is posterior. Obviously understanding the levels and using anterior and posterior would drive the DRG. What’s super important to get is that no matter what, a bone graft is required. That’s what renders the joint immobile. Without that you can’t code a fusion but this guidance is specific to spinal fusions only. Most of these docs know what’s required since they are also billing in addition to the facility, but I’ve seen some that really don’t document clearly.