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.
Medicare Guidelines
The AAOS also notes a reduction in the work RVUs for these procedures will create a rank-order anomaly when compared to other procedures in the total joint family. For example, 24363 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) has a proposed work RVU of 2 1.07. Similarly, 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) has a current work RVU of 2 1.07. The AAOS believes the work values proposed by CMS for 27 130 (work RVU = 15.96) and 27447 (work RVU = 19.30) will create significant inconsistency within the total joint family of procedures that do not reflect current clinical practice and expectations.
Finally, the AAOS notes that the CMS proposed values would result in reimbursement levels for these extensive procedures on elderly patients, many of whom have significant comorbidities, that are lower than if the surgeons used their total global period time to provide multiple mid-level outpatient EIM services (992 13). Clearly, the intensity of work for these procedures is greater than the typical patientlservice for 992 13: “Office ~~isit,for a 55-year-old
establishedpatient with a history of hypertension and hyperlipidemia who presents~for,follow up.” Even at the 2006 work RVUs for these codes, 27130 and 27447 are reimbursed at only a fraction over performing multiple 992 13’s and 27236 is provided at a significant loss (possibly explaining some of the crisis in access to trauma care we are experiencing).
Post-Service Time
The expert panel reviewed the immediate post-service time data from the RUC survey and agreed 30 minutes of immediate post-service time was appropriate. The expert panel noted the immediate post-service time for the reference code 23472 Arthroplasty, glenohumeral joint; total shoulder (nlenoid and proximal humeral replacement (eg, total shoulder)), is also 30 minutes. 30 minutes falls within the range of immediate post-service time for 90-day global procedures – especially with respect to orthopaedic procedures.
The expert panel recommends 30 minutes post-service time for 27130.
Office Visits
The expert panel reviewed the post-operative office visit data from the RUC survey and agreed the number and intensity of office visits were appropriate. The expert panel noted this office visit pattern is identical to the reference code selected by survey respondents, 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid andproximal humeral replacement (eg, total shoulder)), which is a RUC-surveyed code. Both procedures share similar patterns of post-operative care with respect to the number and intensity of office visits. The expert panel recommends 4 office visits (99213~3,99212~1) for 27130.
RVW
The expert panel noted its pre-, intra-, and post-operative time recommendations reflect higher times than the existing Harvard data. The expert panel also noted the overall intensity measures were similar for 27 130 and the most commonly selected reference code, 23472 Arthroplasty, nlenohumeraljoint; total shoulder (glenoid andproximal humeral replacement (en, total shoulder)). The post-operative office visits for 27 130 and the reference code (23472) were identical.
The expert panel noted there was a difference in the number of hospital visits from the Harvard data as compared to the survey data; however, they believed it was inappropriate to make this comparison for several reasons. First, when the Harvard hospital time (9 1 minutes) is compared with the Harvard number of hospital visits (9923 lx8,99238xl), it suggests either a lower intensity visit was used for the Harvard study than is currently used by the RUC, or the number of visits were extrapolated from the total time. Second, it is unclear as to whether more than one hospital visit per day was reported under the Harvard study. If this was the case, it is inconsistent with current RUC and CPT standards which allow a physician to report only one visit per day. Because of these methodological differences, the expert panel believes the Harvard hospital visit data cannot be compared with RUC survey data. The expert panel believes the current RUC survey and NSQIP data accurately reflect the number and intensity of post-operative hospital visits and also believed there has been no decrease in the amount work required for post-operative hospital care.
The expert panel noted the survey median RVW of 20.50 was a slight increase from the current RVW of 20.09. The median survey RVW suggests that survey respondents believe the overall work involved for this procedure has not significantly changed. After consideration of the time, visit, and intensity factors, the expert panel agrees and recommends maintaining the current RVW of 20.09 for 27130.
RVW
The expert panel noted its pre-, intra-, and post-operative time recommendations reflect higher times than the existing Harvard data. The expert panel also noted the overall intensity measures were similar for 27236 and the most commonly selected reference code, 23472 Arthroplasty, glenohumeral joint; total shotllder (glenoid and proximal humeral replacement (eg, total shoulder)). The post-operative office visits for 27236 and the reference code (23472) were identical.
The expert panel noted there was a difference in the number of hospital visits from the Harvard data as compared to the survey data; however, they believed it was inappropriate to make this comparison for several reasons. First, when the Harvard hospital time (100 minutes) is compared with the Harvard number of hospital visits (9923 1×8, 99238xl), it suggests either a lower intensity visit was used for the Harvard study than is currently used by the RUC, or the number of visits were extrapolated from the total time. Second, it is unclear as to whether more than one visit per day was reported under the Harvard study. If this was the case, it is inconsistent with current RUC and CPT standards which allow a physician to report only one visit per day. Because of these methodological differences, the expert panel believes the Harvard hospital visit data cannot be compared with RUC survey data. The expert panel believes the NSQIP data accurately reflect the number and intensity of post-operative hospital visits, and also believes there has been no decrease in the amount work required for post-operative hospital care.
The expert panel noted the survey median RVW of 19.17 was a significant increase from the current RVW of 15.58. The median survey RVW suggests that survey respondents believe the overall work involved for this procedure has increased significantly. However, after consideration of the time, visit, and intensity factors, the expert panel recommends maintaining the current RVW of 15.58 for 27236.
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
