Fusion of spine, sacral and sacrococcygeal region

This code signifies a surgical arthrodesis or natural bony ankylosis that has occurred in the sacral or sacrococcygeal regions of the spine. It indicates a permanent joining of vertebrae in these specific areas, which can be a result of surgical intervention or a pathological process.

Use this code when documentation explicitly states fusion of the sacrum or sacrococcygeal joint. This often follows spinal stabilization procedures or is identified in imaging studies showing congenital or acquired bony union. Supporting documentation includes operative reports detailing sacral fusion, radiology reports confirming sacral or sacrococcygeal ankylosis, or physician notes indicating a history of sacral fusion.

• Ensure the documentation clearly specifies the sacral or sacrococcygeal region; avoid using for fusions in other spinal segments.
• Distinguish between congenital fusion and acquired fusion; this code generally applies to both, but specific congenital codes may exist for certain conditions.
• Do not confuse with codes for spinal instability or spondylolisthesis, which may be reasons for fusion but are not the fusion itself.