Clinical Documentation Tip Sheets

SPINAL FUSIONS

> Specify:

Indication for surgery Associated symptoms Location/ level of involvement Approach and Column Insertion of device or material (eg, interbody fusion device, autologous material, non-autologous material, synthetic material) > Examples: “Anterior approach L3-4 Spinal fusion for lumbar spinal stenosis w/ neurogenic claudication” “Posterior approach T5-7 for thoracic spondylolisthesis w/ radiculopathy” “C3 spondylosis due to generative disc disease w/ myelopathy” > Note: Document a diagnosis rather than a symptom only such as “back pain” as the indication for surgery Document spine deformity when present e.g., scoliosis, kyphosis, kyphoscoliosis, lumbar lordosis