Shoulder arthroplasties are one of the most common surgeries in orthopedics. In fact, in just 2022 alone, an estimated 193,500 arthroplasty procedures were performed. Additionally, these surgeries are very complex and have a high reimbursement rate. So, healthcare providers can’t afford claim denials for these procedures.
CPT code 23472 is a billing code for total shoulder arthroplasty. In this guide, we will teach you how to use this code correctly in your claims. We hope that with the help of this guide, you will be able to increase your revenue. So, let’s start.
CPT Code 23472 – Description
CPT code 23472 is defined as:
“Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement).”
Simply put, 23472 is an orthopedic billing code. It is used to bill a total shoulder arthroplasty, which is a surgical procedure in which both the ball (humeral head) and socket (glenoid) are replaced with artificial implants.
Total shoulder arthroplasty can be performed using two primary techniques: anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA). Both are reported using CPT code 23472. It is a comprehensive surgery and lasts about 2 to 4 hours.
Appropriate Use Cases for CPT Code 23472
To make things clear, here are a couple of scenarios in which CPT code 23472 is applicable:
Severe Osteoarthritis
Let’s suppose a 65-year-old patient comes to an orthopedic clinic. He has chronic shoulder pain and a severely limited range of motion. The patient struggles to perform basic daily activities, like combing her hair or reaching overhead. The physician examines the shoulder in detail and notes significant joint stiffness and crepitus. The imaging results also show signs of degeneration and complete cartilage loss in the glenohumeral joint.
The patient shares that she has been taking conservative medications, which a previous physician prescribed. However, the condition has worsened. The only treatment option is total shoulder arthroplasty. So, the surgeons perform the surgery with the patient’s consent. In the end, the billing department can bill the surgery via CPT code 23472.
Avascular Necrosis of the Humeral Head
Suppose a 52-year-old patient presents with progressive shoulder pain and weakness following long-term corticosteroid therapy for an autoimmune condition. The pain has intensified over several months, severely restricting shoulder movement. MRI imaging reveals avascular necrosis with collapse of the humeral head, indicating disrupted blood supply to the bone. Conservative management has proven ineffective, and the deteriorating joint condition necessitates surgical intervention. The orthopedic surgeon performs total shoulder arthroplasty to replace the damaged humeral head and restore shoulder function.
Finally, the medical billing department codes and submits the claim for reimbursement. In this case, CPT code 23472 is used for the total shoulder replacement procedure.
Modifiers to Append with CPT Code 23472
The following modifiers are used frequently with CPT 23472:
| Modifier | Description | Application |
|---|---|---|
| 22 | Increased Procedural Service | Use with CPT code 23472 when total shoulder arthroplasty is more complicated than usual or additional work is performed. |
| 50 | Bilateral Procedure | Apply to CPT 23472 when performing total shoulder arthroplasty on both sides in the same session. |
| 53 | Discontinued Procedure | Use when shoulder replacement surgery is discontinued due to complications after administering anesthesia. |
| LT | Left Side Procedure | Use when replacing damaged parts of the left shoulder. |
| RT | Right Side Procedure | Append when performing arthroplasty on the right shoulder joint. |
Reimbursement Guidelines for CPT Code 23472
To improve your chances of claim acceptance, keep in mind the following essential points:
Provide Detailed Documentation
Documentation is of vital importance. Your appended documents must justify why a total arthroplasty was required. For 23472, make sure to add the following details:
- Detailed operative report describing the surgical approach, implants used, and any complications encountered.
- Pre-operative imaging demonstrating joint pathology.
- Evidence of conservative treatment failure.
- Functional assessment scores and pain measurements.
- Appropriate ICD-10 diagnosis codes supporting medical necessity.
Be Wary of the Global Period and Bundled Services
CPT code 23472 has a global surgery period of 90 days. This means that pre- and post-surgical services, like office visits and wound care, are already included in the code.
Additionally, a point to note here is that although biceps tenodesis (CPT 23430) is not included with the shoulder replacement code, it is bundled with 23472. Hence, you cannot bill 23430 if you are submitting a claim for total shoulder arthroplasty.
Check the Medicare Reimbursement Rate
The reimbursement rate for code 23472 differs by payer and MAC locality. However, Medicare’s national average reimbursement for total shoulder replacement in facility settings is $1,414.84.
You can check the exact amount for your MAC locality via the PFS Lookup Tool. Here’s how the reimbursement is divided among the three components:
- Pre-operative: 0.10 (10% of the total payment)
- Intra-operative: 0.69 (69% of total payment)
- Post-operative: 0.21 (21% of the total payment)
Final Thoughts on CPT Code 23472
Mastering CPT code 23472 requires attention to detail and a strong grasp of coding guidelines. Accurate code usage, thorough documentation, and efficient billing practices are all essential to get your claims fairly reimbursed on the first try.
However, denials can occur even after following all the guidelines. If you are facing frequent denials, you can always get professional orthopedic billing services from specialized companies like NeuraBill.
