Fusion of spine, site unspecified

This code indicates a surgical arthrodesis of the vertebral column without specifying the particular region (e.g., cervical, thoracic, lumbar). It signifies that two or more vertebrae have been permanently joined together to stabilize the spine, typically to alleviate pain or correct deformity.

Use this code when documentation clearly states "spinal fusion" but does not specify the anatomical site of the fusion. This is often seen in operative reports or discharge summaries where the specific vertebral levels or regions are not detailed. It should be used when more specific site codes (e.g., M43.21-M43.28) cannot be assigned due to lack of information.

• Avoid using this code if the specific spinal region (cervical, thoracic, lumbar, sacral) is documented.
• Query the provider for clarification on the specific site of fusion if possible to allow for more precise coding.
• This code describes the condition of having a spinal fusion, not the procedure itself. The procedure would be coded with a CPT code.