CPT 23472, 23470, 23474 - Arthroplasty procedure codes

CPT Code Description

23470 Arthroplasty, glenohumeral joint; hemiarthroplasty

23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement [e.g., total shoulder])

23473 Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

23474 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

23616 Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacement

SHOULDER REPLACEMENT SURGERY (ARTHROPLASTY)

CONDITIONS OF COVERAGE

Applicable Lines of Business/ Products This policy applies to Oxford Commercial plan membership.

Benefit Type General benefits package Referral Required

(Does not apply to non-gatekeeper products) No Authorization Required (Precertification always required for inpatient admission) Yes Precertification with Medical Director Review Required No Applicable Site(s) of Service

(If site of service is not listed, Medical Director review is required) Inpatient, Outpatient

BENEFIT CONSIDERATIONS

Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if applicable.

Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.

Covered ICD 10


ICD-10-PCS Code ICD-10-PCS Description

ØRRJØJZ Replacement of right shoulder joint with synthetic substitute, open approach
ØRRKØJZ Replacement of left shoulder joint with synthetic substitute, open approach
ØRREØJZ Replacement of right sternoclavicular joint with synthetic substitute, open approach
ØRRFØJZ Replacement of left sternoclavicular joint with synthetic substitute, open approach
ØRRGØJZ Replacement of right acromioclavicular joint with synthetic substitute, open approach
ØRRHØJZ Replacement of left acromioclavicular joint with synthetic substitute, open approach
ØRRJØJ6 Replacement of right shoulder joint with synthetic substitute, humeral surface, open approach
ØRRKØJ6 Replacement of left shoulder joint with synthetic substitute, humeral surface, open approach
ØRRJØJ7 Replacement of right shoulder joint with synthetic substitute, glenoid surface, open approach
ØRRKØJ7 Replacement of left shoulder joint with synthetic substitute, glenoid surface, open approach
ØRRJØØZ Replacement of right shoulder joint with reverse ball and socket synthetic substitute, open approach
ØRRKØØZ Replacement of left shoulder joint with reverse ball and socket synthetic substitute, open approach
ØRWGØJZ Revision of synthetic substitute in right acromioclavicular joint, open approach
ØRWG4JZ Revision of synthetic substitute in right acromioclavicular joint, percutaneous endoscopic approach
Shoulder Coding Reference Guide
ØRWHØJZ Revision of synthetic substitute in left acromioclavicular joint, open approach
ØRWH4JZ Revision of synthetic substitute in left acromioclavicular joint, percutaneous endoscopic approach
ØRWJØJZ Revision of synthetic substitute in right shoulder joint, open approach
ØRWJ4JZ Revision of synthetic substitute in right shoulder joint, percutaneous endoscopic approach
ØRWKØJZ Revision of synthetic substitute in left shoulder joint, open approach
ØRWK4JZ Revision of synthetic substitute in left shoulder joint, percutaneous endoscopic approach

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