Orthopedic Coding Alert

Question: One of our surgeons plans to perform a Delta prosthesis procedure soon, and she asked me whether we should bill the total shoulder replacement code (23472) for the procedure. From what she described to me, her surgery will be more extensive than the normal arthroplasty code. Should we report a separate code for the Delta prosthesis insertion?


Washington Subscriber

 
Answer: If the surgeon can provide sufficient supporting documentation and thinks his work on the prosthesis went over and above what the arthroplasty normally requires, ask him whether he thinks modifier -22 (Unusual procedural services) is warranted.
 
If so, you can append modifier -22 to 23472 (Arthroplasty, glenohumeral joint; total shoulder [glenoid and proximal humeral replacement [e.g., total shoulder]) 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 she performed advanced rotator cuff arthroplasty using a "Delta Reverse Total Shoulder Replacement."

She should explain that the patient's condition (such as arthritis with an irreparable rotator cuff tear) was so severe that the Delta prosthesis was a last resort because the patient had no shoulder function.

The surgeon should also include a description of the procedure that she performed and, if applicable, a request for additional reimbursement.
 
For example, "The surgery required extensive dissection and exposure of the glenoid, then placement of a glenoid component that requires an advanced technique to place. The Metaglene component requires four locking screws that are very difficult to place."