Spinal Fusion Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

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Brief Description
Legible handwritten physician and/or clinician signatures
Valid electronic physician and/or clinician signatures
Physician or Non-Physician Practitioner (NPP) order(s) for the date of service (including admission order, if applicable)
Physician certification of medical necessity of admission, if applicable
Legible procedure note or report that includes sufficient detail to allow reconstruction of the procedure
Records of patient's condition before, during and after this billing period to support medical necessity and the reason the service was provided
  • History and physical, office visit notes, emergency room records, progress notes, nurse notes, treatment records, consultation reports and all other pertinent medical records
Initial pre-procedural evaluation and/or the history and appropriately focused musculoskeletal physical examination including:
  • Duration, character, location and radiation of pain
  • Activities of daily living (ADL) limitations
  • Detailed physical examination
Documentation supporting unsuccessful and reasonable attempt at conservative therapy (non-surgical medical management), if appropriate. Examples include, but are not limited to:
  • Trial of Nonsteroidal Anti-inflammatories (NSAIDs) or analgesics
  • Supervised physical or occupational therapy or documented contraindication to therapy
  • Flexibility and muscle strengthening exercises
  • Assistive device use
  • Weight reduction, as appropriate
  • Diagnostic or therapeutic injections, as appropriate
  • Note: A statement of "failed conservative/outpatient treatment" is not sufficient.
Pre-procedure radiological reports and other pertinent diagnostic test results to support need/medical necessity for procedure
  • When no official imaging report is available, the following components must be present within medical records: date(s) the imaging was completed, type(s) of imaging/exam and detailed findings
Medication Administration Records (MAR)
Observation orders and daily progress notes, if applicable
Rehabilitation records:
  • Physical, Occupation and Speech therapy notes, if applicable
Disposition/discharge notes/hospital discharge summary
Full detailed itemized bill indicating revenue code
Coding query form, if applicable
Quality Improvement Organization (QIO) letter, if applicable
Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable
Advance Beneficiary Notice of Noncoverage (ABN), if applicable

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Acute Inpatient Prospective Payment System (PPS) Hospital webpage for additional information and resources. To review situations that may arise where a spinal fusion is approved without conservative treatment being clearly documented, see "Documentation Errors" section of the SPINAL FUSION Services: Documentation Requirements Coverage Article.

Last Updated Jun 18 , 2024

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.