About this policy
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Total Shoulder Arthroplasty L39956. Documentation Requirements: All documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be made available to the contractor upon request. The patient's medical record must contain documentation that fully supports the medical necessity for services included in the LCD. (See Coverage Indications, Limitations and/or Medical Necessity .) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 23472 | HCPCS | Covered |
| C40.01 | ICD10CM | Covered |
| C40.02 | ICD10CM | Covered |
| C43.61 | ICD10CM | Covered |
| C43.62 | ICD10CM | Covered |
| C44.602 | ICD10CM | Covered |
| C44.609 | ICD10CM | Covered |
| C49.11 | ICD10CM | Covered |
| C49.12 | ICD10CM | Covered |
| C76.41 | ICD10CM | Covered |
| C76.42 | ICD10CM | Covered |
| D03.61 | ICD10CM | Covered |
| D03.62 | ICD10CM | Covered |
| M05.011 | ICD10CM |