Find information on Reverse Total Shoulder Arthroplasty diagnosis, including clinical documentation requirements, ICD-10-CM and CPT coding guidelines, postoperative care, and healthcare resources. Learn about proper medical coding for Reverse Total Shoulder Arthroplasty procedures and complications, ensuring accurate reimbursement and compliant documentation. This resource offers guidance for healthcare professionals involved in the diagnosis and treatment of Reverse Total Shoulder Arthroplasty.
Also known as
Reversal shoulder replacement
Insertion of reverse total shoulder prosthesis.
Shoulder joint replacement
Procedures involving shoulder joint replacement.
Mech compl shoulder replacement
Mechanical complications of shoulder replacement.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the reverse total shoulder arthroplasty initial or subsequent encounter?
Initial encounter
Any complications?
Subsequent encounter
Encounter for routine healing/follow-up?
When to use each related code
| Description |
|---|
| Reverse Total Shoulder Arthroplasty |
| Total Shoulder Arthroplasty |
| Rotator Cuff Repair |
Incorrectly coding the side of the body (left or right) for the reverse total shoulder arthroplasty impacting reimbursement.
Failing to code separately for specific implants used during the procedure, leading to lost revenue.
Using a non-specific diagnosis code when a more specific code is available for the reason for the reverse TSA, affecting data accuracy.
Patient presents with chronic shoulder pain and dysfunction, consistent with the diagnostic criteria for reverse total shoulder arthroplasty (RTSA) candidacy. The patient reports significant pain interfering with activities of daily living (ADLs), including limited range of motion, weakness, and difficulty sleeping. Symptoms are consistent with glenohumeral osteoarthritis, rotator cuff tear arthropathy, or failed prior shoulder surgery, as confirmed by radiographic imaging including X-rays and potentially MRI or CT scan. Conservative management, such as physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroid injections, has provided insufficient relief. Physical examination reveals limited active and passive range of motion, crepitus, and positive impingement signs. The patient demonstrates a pseudoparalysis or significant rotator cuff deficiency precluding a standard anatomic total shoulder replacement. Surgical intervention with reverse total shoulder arthroplasty is indicated to alleviate pain, improve function, and restore quality of life. Risks and benefits of the procedure, including infection, dislocation, nerve injury, and implant loosening, were thoroughly discussed with the patient, and informed consent was obtained. Preoperative planning includes templating of radiographs to determine optimal implant size and position. Postoperative care will involve physical therapy, pain management, and regular follow-up appointments to monitor healing and functional recovery. ICD-10 codes for the primary diagnosis will be determined based on the underlying etiology, such as M19.011 for primary osteoarthritis, right shoulder, or M75.41 for rotator cuff tear, right shoulder. CPT codes for the surgical procedure, such as 23472 for reverse total shoulder arthroplasty, will be documented accordingly. The patient's overall health status and comorbidities, including any relevant medical history such as diabetes, hypertension, or cardiovascular disease, will be carefully considered in perioperative management.