Know Your Options for This Shoulder Resurfacing Procedure
Question: I have a report for a patient who had a previous shoulder resurfacing procedure performed, where only the damaged portion of the humeral head was replaced with a metal cap. The patient is now undergoing conversion to a reverse total shoulder arthroplasty. The surgeon described the case as a “revision of a resurfacing hemiarthroplasty to a reverse total arthroplasty.” Would this be considered a revision arthroplasty since a prosthetic cap is being removed and replaced, or should I code the procedure as a primary total shoulder arthroplasty (23472) because the previous implant did not include a ball and stem? Pennsylvania Subscriber Answer: You have three coding pathways available to choose from depending on the payer. If the patient is a Medicare or Medicaid beneficiary, you can consider using 23472 (Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))) appended with modifier 22 (Increased procedural services); or report 23474 (Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component) with modifier 52 (Reduced services). For commercial payers, assign 23472 and 23334 (Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component) with modifier 59 (Distinct procedural service). This code pair is the most appropriate from a reimbursement standpoint and best represents the procedure performed. However, 23334 is a column 2 code of 23472, according to the National Correct Coding Initiative (NCCI) edit pairs. This means that the prosthesis removal is bundled into the arthroplasty procedure, but you can unbundle the procedures and report 23334 separately with modifier 59 if the documentation shows that the prothesis removal was a distinct and separate service performed at the same time as the arthroplasty. Of course, double-check with the individual payer to submit the claim according to their payment preferences. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
