Looking for a comprehensive guide to bill CPT code 23472 accurately? You are at the right place! Shoulder arthroplasties are quite common. The Journal of Shoulder and Elbow Surgery has revealed that healthcare providers are going to perform up to 350,558 shoulder replacement procedures in 2025.
You might also be an expert at completely replacing the damaged parts of a shoulder, but do you know its coding and billing requirements? CPT code 23472 is the usual choice for this service, but its details often confuse even the most experienced coders.
Today, we will discuss this code in detail, including applicable modifiers and billing tips, so you can use it correctly when filing claims.
CPT Code 23472 – Description
As hinted in the intro, CPT code 23472 reports a total shoulder arthroplasty (TSA). In simple terms, it describes a complex surgical replacement of damaged portions of the shoulder joint with artificial parts. But what does the word total mean in this description?
Specifically, it refers to the replacement of both the humeral head (the rounded, top part of the humerus bone) and the glenoid cavity (a shallow, pear-shaped surface) of the shoulder joint with prosthetic implants. What are the primary goals of this procedure? To reduce shoulder pain and functional limitations due to severe conditions like arthritis.
In short, CPT code 23472 covers two things:
- Removal of the damaged shoulder joint parts (humeral head and glenoid cavity)
- Placement of prosthetic components
Scenarios Where CPT Code 23472 is Applicable
Want to gain a better understanding of CPT code 23472? Here is how you can apply this procedural code in various situations:
Total Shoulder Replacement due to Glenohumeral Osteoarthritis
Did you know that 5 to 17% of people’s shoulder issues are due to glenohumeral osteoarthritis (a degenerative shoulder joint condition)? So, for our first example, let’s consider a 58-year-old man with this problem. He has been on conservative treatments for 5 years. However, he seeks out an orthopedic surgeon after experiencing immense pain and a frozen shoulder for some time.
Suspecting loss of cartilage, the healthcare provider conducts a detailed examination to confirm his suspicion. He then performs a total shoulder replacement surgery to reduce the patient’s pain and restore function. His billing team uses CPT code 23472 to report the procedure.
Total Shoulder Arthroplasty to Address Rotator Cuff Tear
Around 3 million Americans have a rotator cuff (group of muscles and tendons surrounding the shoulder joint) tear. So, how do these injuries happen? They occur due to repetitive overhead activities or traumatic events, like falls or accidents.
So, for our second scenario, let’s envision something similar. Suppose a 24-year-old injures his rotator cuff while moving to a new home. The main cause? Lifting a heavy box off the ground without proper form. In the beginning, he does not notice anything, but after some time, he starts experiencing excruciating pain with certain arm movements.
He arrives at a hospital where a healthcare provider injects a cortisone shot to reduce his pain. However, his shoulder pain and inflammation continue to worsen with time. Finally, after some months, he visits an orthopedic clinic where the physician identifies the main problem: a rotator cuff tear.
The orthopedic surgeon then conducts a reverse total shoulder arthroplasty to reduce the patient’s pain and uses CPT code 23472 to bill for this procedure.
Total Shoulder Arthroplasty for Replacing Damaged Parts due to Rheumatoid Arthritis
Did you know that chronic arthritis can also damage the cartilage? Since this autoimmune disease affects more women than men, consider a 38-year-old woman with long-standing rheumatoid arthritis.
Tired of her persistent shoulder pain and stiffness, she arrives at an outpatient department for some pain relief. The healthcare provider evaluates her condition, takes her history, and conducts several imaging tests to diagnose the problem. The results reveal a damaged humerus head and glenoid cavity.
After trying and failing to treat her condition with medications for 2 months, the physician performs a total shoulder arthroplasty. He replaces the patient’s damaged shoulder parts with implants and files a claim using CPT code 23472.
Applicable Modifiers for CPT Code 23472
So, which modifiers can help you report additional details about total shoulder arthroplasty? Here are several options you can use with CPT code 23472:
Modifier LT
Did you replace the damaged parts of the left shoulder? Use modifier LT with CPT code 23472 to specify this information.
Modifier RT
If you performed arthroplasty on the right shoulder joint, append modifier RT to CPT code 23472.
Modifier 50
Did both shoulder joints need replacement within the same session? Apply modifier 50 to CPT code 23472 if you performed total shoulder arthroplasty on both sides.
Modifier 22
Was the total shoulder arthroplasty more complicated than usual? Did you perform additional work due to complications? If you did, report this information by using modifier 22 with CPT code 23472 to indicate increased procedural service.
Modifier 53
Did you discontinue the shoulder replacement surgery due to some complication? There is always a risk of nerve damage during this procedure. So, if you abandoned the procedure due to an unexpected situation after administering anesthesia, use modifier 53 with CPT code 23472.
CPT Code 23472 – Billing & Reimbursement Guidelines
Don’t want to see another denial for total shoulder replacement surgery? Follow these simple billing and reimbursement guidelines for CPT code 23472.
Use 23472 for Total Shoulder Arthroplasty
Keep the word total in mind while choosing this code. As mentioned earlier, CPT code 23472 refers to the replacement of both the humeral head and the glenoid cavity with metal and plastic implants. Therefore, only use it when you have performed such surgery. If you have only replaced half of a damaged joint, use another code (e.g., CPT code 23470 for humeral head replacement).
Do Not Bill Separately for Bundled Services
CPT code 23472 refers to a major surgery, and do you know what that means? It has a 90-day global period. Hence, it includes several pre-, intra-, and post-operative services, such as pre-operative office visit, surgery itself, and wound closure. Pay close attention to its bundling requirements and avoid billing these services separately.
Specify Total Shoulder Arthroplasty’s Location with Modifiers
Coding for total shoulder arthroplasty is incomplete without anatomical modifiers, like LT and RT. You must specify the shoulder (left or right) on which you performed the surgery. If the procedure was bilateral, use modifier 50 with CPT code 23472.
Justify the Medical Necessity with Complete Documentation
You must also justify the medical necessity of total shoulder arthroplasty. For that, you should maintain proper documentation in the patient’s medical record. In simple terms, the documentation must include the following details:
- Patient’s relevant medical history
- Physical examination
- Results of relevant diagnostic tests or procedures
- Appropriate ICD-10 codes
You should also submit an operative report to the appropriate payer with the following details:
- Surgical approach (Deltopectoral)
- Implants used (metal or plastic)
Review Payer Requirements for CPT code 23472
Don’t forget this important step! Some insurance payers may require prior authorization for this procedure. Therefore, always verify payer-specific requirements, including Medicare’s Local Coverage Determinations (LCDs), before filing a claim for total shoulder arthroplasty.
Summary
Coding for total shoulder arthroplasty requires some attention. But with proper knowledge, you can ace it the first time. CPT code 23472 represents this procedure. Hence, you can use it to report that you have replaced both the humeral head and glenoid cavity of a patient’s shoulder joint with prosthetic implants. We have already clarified all the details you need to know about this code in our guide, including when it applies, the modifiers to use with this code, and common billing mistakes to avoid. However, if you don’t have the time, partner with an experienced billing company that specializes in orthopedic billing services, it will make your billing more accurate and compliant.
