Surgical replacement of both the humeral head and glenoid components of the glenohumeral joint, including traditional total shoulder arthroplasty and reverse total shoulder arthroplasty.

Verified May 8, 2026 · 8 sources ↓

Medicare: $1,300.30
Total RVUs: 38.93
Global, days: 90
Region: Shoulder

Drawn from CMSOrthobillingexpertAAPCZimmerbiometAetna

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 8 cited references ↓

Operative report must name the surgical approach (e.g., deltopectoral) — notes that say 'standard approach' draw audit flags.
Specify implant type, manufacturer, and configuration (conventional vs. reverse); document which components were placed (humeral and glenoid).
Document failed conservative treatment (physical therapy, injections, NSAIDs) to establish medical necessity.
Imaging findings (X-ray, MRI, or CT) corroborating the degree of glenohumeral joint destruction or fracture sequelae.
If modifier 22 is appended, the operative note must explicitly quantify the additional complexity — e.g., extent of scarring from prior surgeries, degree of bone loss, need for bone grafting.
Prior authorization documentation and payer approval number should be retained in the claim file.
ICD-10 diagnosis codes must correspond precisely to the documented indication (e.g., primary osteoarthritis vs. rotator cuff tear arthropathy vs. fracture).

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 25 Significant separate E/M 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 57 Decision for surgery 58 Staged or related 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant LT Left side RT Right side

Related ICD-10 diagnoses

Diagnoses commonly reported with CPT 23472.

Source · CMS LCDs · AAOS specialty guidance · claims-pattern analysis

M19.011 M19.012 M75.01 M75.02

What this code covers

Source · Editorial summary grounded in 8 cited references ↓

CPT 23472 covers total shoulder arthroplasty — removal of the native or failed prosthetic glenohumeral joint and replacement of both the proximal humerus and glenoid with prosthetic implants. Use this code for both conventional total shoulder replacement and reverse total shoulder arthroplasty; the implant configuration (ball on glenoid, socket on humerus) does not change the code. Per NCCI policy, separately billing prosthesis removal codes 23333, 23334, or 23335 alongside 23472 is prohibited — removal of a prior failed prosthesis is bundled.

The 90-day global period means all routine post-op care, dressing changes, and follow-up visits through day 90 are included. Services unrelated to the shoulder replacement during that window require modifier 24 (E/M) or 79 (unrelated procedure). A related return to the OR during the global period — for a complication such as wound dehiscence or component instability — bills with modifier 78.

For payer-specific coverage, note that Aetna explicitly excludes 23472 when the indication is an irreparable rotator cuff tear without other qualifying pathology. Medicare LCDs govern medical necessity for traditional total shoulder vs. reverse configuration; verify the applicable LCD before submitting. Most commercial payers require prior authorization. ICD-10 diagnosis codes must match the operative indication precisely — primary glenohumeral osteoarthritis (M19.011/M19.012), rotator cuff tear arthropathy (M75.10x), or fracture sequelae — because ICD-code-to-CPT mismatches are a leading denial driver.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	21.58
Practice expense RVU	12.99
Malpractice RVU	4.36
Total RVU	38.93
Medicare national rate	$1,300.30
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$1,300.30
HOPD (APC 5116) Hospital outpatient department	$17,913.59
ASC (PI J8) Ambulatory surgical center (freestanding)	$13,911.66

Common denial reasons

The recurring reasons claims for CPT 23472 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Missing or expired prior authorization — most commercial payers and many Medicare Advantage plans require it for 23472.
Diagnosis code mismatch: billing M75.10x (rotator cuff syndrome) instead of the arthropathy or fracture code that justifies joint replacement.
Separately billing 23334 or 23335 for prosthesis removal when converting a failed implant — NCCI bundles removal into 23472.
Insufficient documentation of conservative treatment failure before proceeding to total shoulder arthroplasty.
Laterality modifier (LT or RT) omitted — payers require it on unilateral joint replacement claims.
Aetna-specific denial when the sole indication is irreparable rotator cuff tear without a covered qualifying condition.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 8 cited references ↓

01Is 23472 used for both conventional and reverse total shoulder arthroplasty?

Yes. Report 23472 for both configurations. The AAPC and ACGME case log guidelines both confirm that reverse total shoulder arthroplasty maps to 23472 — the switched implant orientation does not warrant a different code.

02Can I separately bill for removing a failed prosthesis when performing a conversion to total shoulder arthroplasty?

No. NCCI policy explicitly bundles prosthesis removal (23333, 23334, 23335) into 23472 when the removal is part of the same arthroplasty procedure. Billing either removal code alongside 23472 for an ipsilateral shoulder will be denied.

03What modifiers are required for a unilateral total shoulder replacement?

Always append LT or RT. Most payers require a laterality modifier on joint replacement claims, and omitting it is a straightforward, preventable denial. Add modifier 50 only if both shoulders are replaced in the same operative session, which is rare.

04How does the 90-day global period affect billing for post-op complications?

Routine post-op care is bundled through day 90. If the patient requires an unplanned return to the OR for a complication related to the shoulder replacement — such as component loosening or wound infection — bill with modifier 78. An unrelated procedure during the global period gets modifier 79. An unrelated E/M visit during the global period requires modifier 24.

05When should modifier 22 be appended to 23472?

Append modifier 22 when the case involves substantially greater work than a routine total shoulder — for example, severe bone loss requiring structural grafting, multiply-revised shoulder with extensive scarring, or significant intraoperative anatomic distortion. The operative note must explicitly describe the additional work; a generic statement that the case was 'complex' is insufficient for most payers.

06Does Aetna cover 23472 for all indications?

No. Aetna's clinical policy bulletin explicitly excludes 23472 when the sole indication is an irreparable rotator cuff tear. Verify the covered diagnosis before submitting to Aetna, and confirm the ICD-10 code reflects a qualifying condition such as glenohumeral osteoarthritis or fracture sequelae.

07What is the difference between 23472 and 23473/23474?

23472 is for primary total shoulder arthroplasty. Use 23473 when revising either the humeral or glenoid component of a prior total shoulder replacement, and 23474 when revising both components. Never use 23472 for a revision — it will bundle or mismatch against prior claim history.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the surgical approach by name, implant configuration (conventional vs. reverse), component details, and bone loss or grafting requirements from dictation in real time. It flags when the operative note lacks explicit documentation of approach or implant type — the two most common operative-note deficiencies that trigger audits and modifier 22 denials on 23472 claims.

See how Mira captures CPT 23472 documentation