Orthopedic Coding Alert

Question: Which code should we report for a reverse total shoulder arthroplasty?

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Answer: You should report 23472 (Arthroplasty, glenohumeral joint; total shoulder [glenoid and proximal humeral replacement (e.g., total shoulder)]) for the reverse total shoulder arthroplasty.

If the surgeon can provide sufficient supporting documentation and thinks his work on the arthroplasty went over and above what the total shoulder replacement normally requires, ask him whether he thinks modifier 22 (Increased procedural services) is warranted. Keep in mind this is extremely rare. For instance, you might be able to apply modifier 22 when a patient who has undergone a previous shoulder surgery is “converted” to a total shoulder. CPT® has established the concept of increased complexity associated with conversion procedures via code 27132 (Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft). In any case, if your surgeon believes the case warrants modifier 22, you can report 23472-22 to denote the additional work the surgeon performed.

Include the operative report and a letter with your claim, in which the surgeon should explain that he performed advanced rotator cuff arthroplasty using a reverse total shoulder replacement.

Have the physician explain the patient’s condition and discuss why the procedure was more complicated than a standard arthroplasty.

Note: The ICD code or reverse TSR is likely in your future.