Helpful Codes For Osteochondral Allograft Procedures In The Shoulder

The following coverage, coding, and payment information is provided for informational purposes only and should not be construed as legal advice. The information was compiled from various resources and is subject to change.

Providers should exercise independent clinical judgment when selecting codes and submitting claims to accurately reflect the services rendered. Providers are encouraged to contact third-party payers for specific information on their coverage, coding, and payment policies as payment for medical products and services is affected by numerous factors.

Letter of Medical Necessity

Shoulder resurfacing procedures are considered the best option for specific patients. However, because they are not done in high volume, there have been few high-level outcomes published to date. As a result, health plans are challenged to develop broad, positive coverage determinations for these procedures.

In order to obtain coverage and reimbursement for specific patients indicated for these procedures, the physician typically will need to use the CPT code for an unlisted procedure (see below) and craft a letter to the payer describing the patient’s clinical situation. The letter should clearly detail why this course of action is the most appropriate treatment alternative.

Often it is useful to reference more commonly performed and somewhat similar shoulder surgeries, with an explanation of the added complexity of the specific case and why osteochondral resurfacing is indicated. This additional step may be helpful in gaining approval from the health plan.

Insurance Coding

ICD-10 codes are much more specific than previous coding systems. A range of codes indicates there are several options available. For example, there is a separate code for a right, a left or a bilateral procedure. It is important to verify the correct code is being used to help ensure insurance authorization.

Typical ICD-10 Codes

• M24.111-M24.112, M24.119 – Other articular cartilage disorders, shoulder
• M24.811-M24.812, M24.819 – Internal derangement, shoulder
• M89.511-M89.512, M89.519 – Osteolysis, unspecified shoulder
• M93.211-M92.212, M92.219 –Osteochondritis dissecans, shoulder
• M93.811-M93.812, M93.819 – Other specified osteochondropathies, shoulder
• M94.8X1 – Other specified disorders of cartilage, shoulder

Typical ICD-10 Procedure Codes

• 0RUJ0KZ-0RUK4KZ – Supplement shoulder joint with non-autologous tissue substitute

Typical CPT Codes

• 23470 – Arthroplasty, glenohumeral joint; hemiarthoplasty
• 23472 – Arthroplasty, glenohumeral joint; total shoulder
• 23929 – Unlisted procedure, shoulder
• 29999 – Unlisted procedure, arthroscopy

Typical HCPCS Codes

• C1762 – Billing code for allograft

Typical Revenue Codes (for form UB-04)

• 278 - Other implants

CPT Modifiers

• RT – Right
• LT – Left

Updated on: 21/10/2021