Orthopedic Coding Alert

Know when to report arthroplasty revisions.

Patients experiencing pain and stiffness in their shoulders might require surgery to repair or replace the joint to ensure continued functionality. Orthopedic surgeons have multiple options for shoulder arthroplasty, and as an orthopedic coder, you need to know how to report the procedures and associated diagnoses to help ensure the practice receives reimbursement.

Familiarize yourself with shoulder surgeries and the conditions that warrant the procedure.

Get to Know the Types of Shoulder Arthroplasty

Arthroplasty is a surgical procedure where the surgeon removes damaged portions of bone and replaces structures with implants. A patient can experience stiffness, weakness, and pain in the shoulder joint when the ball-and-socket joint is damaged.

Joint explanation: The shoulder is an example of a ball-and-socket joint, where the upper arm bone’s round head (ball) fits into the shoulder’s socket.

Surgeons perform partial or total shoulder arthroplasties to treat the patient’s condition. During partial shoulder arthroplasty, the surgeon replaces just the ball of the joint with an implant. The physician performs this procedure when the rounded head of the upper arm is damaged, but the shoulder socket is intact.

You’ll assign 23470 (Arthroplasty, glenohumeral joint; hemiarthroplasty) to report a partial shoulder replacement surgery. Hemiarthroplasty is a term that means partial replacement; so, if you see this term or partial shoulder arthroplasty in the procedure report, you’ll know to report 23470.

Total shoulder arthroplasty involves the physician removing and replacing both the ball and socket of the joint. A reverse total shoulder replacement is the same as a total shoulder replacement, but the implants are switched. The provider attaches the ball to the shoulder blade and attaches the socket to the upper arm.

Report 23472 (… total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))) when the surgeon performs a total shoulder arthroplasty. This includes removal and replacement of the damaged upper humerus bone and shoulder socket. You’ll assign this code regardless of whether the provider performs a traditional total shoulder joint replacement or a reverse total shoulder arthroplasty.

Report Arthroplasty Revisions Correctly

Over time, the implants may become dislodged or break, which will require a surgeon to remove and replace the pieces to ensure joint mobility. The surgeon may use tissue from another part of the body, called an allograft, to stabilize the new prosthesis. Assign 23473 (Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component) when the provider performs a shoulder arthroplasty revision that affects either the humeral (upper arm) or glenoid (shoulder socket) component.

On the other hand, if the physician revises both components of the total shoulder arthroplasty, then you’ll assign 23474 (… humeral and glenoid component) for the procedure.

Identify Shoulder Injury ICD-10-CM Codes

Orthopedic surgeons perform shoulder arthroplasty to alleviate pain, stiffness, and other symptoms the patient is experiencing due to the damaged joint. You must show medical necessity for the shoulder surgery to ensure reimbursement; otherwise, the payer will deny your claim. You’ll exhibit the reason for the procedure through detailed documentation and assigning the correct ICD-10-CM codes.

Common conditions that cause joint damage include:

• Osteoarthritis: This degenerative disease damages the cartilage at the ends of bones over time. As a result of the wear and tear, the joint doesn’t move smoothly. You’ll assign a code from the M19.01- (Primary osteoarthritis, shoulder) code subcategory to report a shoulder osteoarthritis diagnosis. A 6^th character to specify laterality is needed to complete the code.
• Rotator cuff injury: A collection of tendons and muscles surrounding the shoulder joint make up the rotator cuff. Tears to the muscles and tendons are what cause the injury, and the joint’s cartilage and bone may become damaged depending on the severity of the laceration. The ICD-10-CM code set features several codes that allow you to identify a rotator cuff injury as traumatic or nontraumatic.
• Nontraumatic: Look to the M75.1- (Rotator cuff tear or rupture, not specified as traumatic) code subcategory when a rotator cuff injury develops over time. This code requires a 5^th character to specify the tear severity and a 6^th character to identify the laterality.
• Traumatic: Use the S46.0- (Injury of muscle(s) and tendon(s) of the rotator cuff of shoulder) code subcategory to report a traumatic rotator cuff injury. The codes in this subcategory require a 5^th character to report the severity, a 6^th character to identify the laterality, and a 7^th character to indicate the type of encounter.
• Fracture: The ball portion of the ball-and-socket joint is the rounded head of the humerus bone, and when the head or the upper end of the humerus is fractured (broken), a surgeon will replace the fractured portion with an implant. Like a rotator cuff injury, the fracture can develop over time (pathological) or as a result of an external force acting on the bone (traumatic).
• Pathological fracture: You’ll assign a code from the M84.42- (Pathological fracture, humerus) code category to report a fracture of the humerus that developed over time. A complete code requires a 6^th character to identify laterality and a 7^th character specifying the type of encounter.
• Traumatic fracture: If the surgeon performs shoulder arthroplasty due to the patient experiencing a traumatic fracture to the humerus, you’ll look to the S42.29- (Other fracture of upper end of humerus) code set. This code subcategory also includes anatomical neck of humerus fractures and articular head of humerus fractures. The 6^th character lets you identify if the fracture is displaced or not displaced as well as the laterality. You’ll also need a 7^th character to specify the type of encounter for the injury.

Remember: According to the ICD-10-CM Official Guidelines, if a fracture isn’t documented as displaced or not displaced, you’ll report the fracture as displaced.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC