Published 11/20/2025
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Julie Bishop, MD, FAAOS
Accurate coding in shoulder surgery requires careful alignment of surgical technique, clinical documentation, and payer policy. Controversy repeatedly arises with several procedures, including remplissage, contracture release, axillary nerve neurolysis, biceps tendon management, subscapularis handling, biologic augmentation, and computer-assisted navigation. Misapplication of codes not only risks payer scrutiny but also undermines the integrity of orthopaedic coding practices.
Remplissage
Surgeons should keep in mind the following excerpt as stated in the Current Procedural Terminology (CPT) code book: “Select the name of the procedure or service that accurately describes the services performed. Do not select a CPT code that merely approximates the service provided. If no specific code exists, then report the service using the appropriate unlisted procedure or service code.” Therefore, when deciding on the best way to code for performing a remplissage, choosing the code 29827, which is arthroscopic rotator cuff repair, is incorrect, as there is no rotator cuff tear requiring repair.
According to recommendations from the AAOS Coding Coverage and Reimbursement Committee (CCRC) and the July 2015 CPT Assistant article, surgeons should add modifier 22 when performing remplissage in addition to an arthroscopic Bankart repair, as this will account for the extra work performed. Utilization of the unlisted arthroscopic code 29999 is also appropriate for remplissage and acceptable to use. However, surgeons should keep in mind that payers apply variable payment policies to modifier 22 and unlisted codes.
Regardless of which approach is chosen, the goal is to be reimbursed for clearly distinct work performed. Importantly, remplissage should be recognized as a procedure that addresses instability, rather than a rotator cuff repair.
Total shoulder arthroplasty
When coding for a total shoulder arthroplasty (TSA) surgery, whether anatomic or reverse TSA, all surgeons should keep in mind the Global Service Data (GSD), which clearly outline what is and is not included in a shoulder replacement (code 23472). Although biceps tenodesis (23430) is NOT included with the shoulder replacement code in the GSD, under National Correct Coding Initiative (NCCI) edits, it IS bundled with 23472. Therefore, one cannot code for biceps tenodesis when billing for TSA for Medicare and all carriers that follow NCCI.
In addition, re-attaching the biceps, regardless of the location it is reattached, is considered a biceps tenodesis and should not be confused with a tendon transfer (23395); therefore, it is incorrect coding to bill for a tendon transfer when simply re-attaching the biceps after a tenotomy.
Furthermore, repairing the subscapularis is included in the work of a shoulder replacement as outlined in the GSD. Even if the tendon is repaired in a more medial or lateral position, this is still included and not considered a tendon transfer. Utilizing 23395 is inappropriate in this situation.
Another coding misconception is the utilization of 23020 with 23472. 23020 is considered a capsular contracture release (e.g., sever-type procedure) and is considered an inherent part of performing TSA. As such, it is also listed as an included component of 23472 in the GSD. Therefore, it is incorrect coding to bill for 23020 at the time of a shoulder replacement.
It is also incorrect coding to bill for axillary nerve neurolysis (64708/64713) as part of TSA, as preservation of the axillary nerve is considered routine. Therefore, dissection and identification of the nerve during the course of routine TSA is not considered axillary nerve neurolysis. For a thorough explanation of when to utilize 64708, the treating surgeon should refer to the CPT Assistant neurolysis and neuroplasty article published in 2012.
Rotator cuff repair
Biologic augmentation and supplementation during rotator cuff repairs are increasingly recognized as beneficial adjuncts to aid in healing and lowering retear rates in select cases. However, the use of biologics also adds time and difficulty to the procedure, requiring appropriate coding and reimbursement. When performing an arthroscopic rotator cuff repair (29827) that utilizes augmentation, the CCRC recommends using modifier 22 to account for additional time and effort. The reason for the additional procedure, details of how it was done, and comments on the increased work/time/intensity should be documented in the operative report.
If the procedure is done arthroscopically and the surgeon did not perform a repair of the rotator cuff, report an unlisted arthroscopy code 29999 (unlisted procedure, arthroscopy), referencing 29827 as a comparable code. Placing biologic augmentation onto a rotator cuff without a repaired tear is not considered 29827 and should not be billed as such. Augmentation material itself is considered inherent and not separately reportable under NCCI bundling. The ambulatory surgery center or hospital may bill for the implant on the facility claim; however, it is not appropriate for the physician to bill.
Computer-assisted navigation
Finally, it is important to address the utilization of CPT code 20985, which describes computer-assisted surgical navigation. Computer navigation and preoperative digital templating with computer software are not the same. Preoperative digital templating is included in shoulder replacement (23472) and is not separately billable. Code 20985 requires the intraoperative, real-time use of computer software to make assessments and adjustments during surgery. This generally involves the use of intraoperative trackers and calibration, such as incisions to place fixation pins, array attachment, anatomy data-point registration, interface with the computer, robot-guided cuts, intraoperative reassessment with computer navigation, removal of pins, and then wound closure. Many TSA systems now have computer-based planning systems; however, these planning interfaces are not considered computer-assisted surgical navigation, so reporting 20985 is incorrect. There are newly approved pre-optimization codes, and surgeons can investigate these codes for potential use.
Conclusion
Although numerous coding controversies surround shoulder surgery, the overarching principle is that dual reporting of codes should remain the rare exception. Most ancillary steps — contracture release, neurolysis, biceps work, subscapularis handling, and biologic augmentation — are bundled into the primary code. Separate reporting should be reserved for well-documented, independent pathologies with clear diagnostic and operative evidence. For high-volume surgeons, accurate and ethical coding is essential, as it reduces payer scrutiny, minimizes the risk of denials or bundling, and preserves the credibility of orthopaedic coding.
Julie Bishop, MD, FAAOS, is a member of the CCRC, a representative of American Shoulder & Elbow Surgeons, and an AAOS CPT alternate advisor.