Total Shoulder Arthroplasty

Published 07/29/2025

Total shoulder arthroplasty (TSA), also known as total shoulder replacement, is a surgical procedure that replaces both the glenoid and proximal humerus with prosthetic parts.

TSA is a well-established treatment for various painful and debilitating shoulder conditions. It can provide pain relief, improve function, reduce disability, and enhance quality of life. The shoulder joint is the third most commonly replaced joint after the hip and knee, and in the United States, the rate of primary shoulder arthroplasties has increased 103.7 percent between 2011 and 2017. Due to the high volume of these claims, the Centers for Medicare & Medicaid Services (CMS) has had multiple auditing entities reviewing claims including the Recovery Auditor, Comprehensive Error Rate Testing (CERT) Contractor, and Medicare Administrative Contractors (MACs). 

Recent studies have suggested TSA may be performed safely and efficiently as an outpatient in properly selected patients. If the patient requires admission, the two-midnight rule must be utilized.

TSA is reasonable and necessary for each of the following conditions:

  1. Degenerative glenohumeral joint disease including osteoarthritis (OA), or post-traumatic arthritis, or rheumatoid arthritis (RA), or osteonecrosis, or arthropathy with rotator cuff deficit when all the following are present:
  • Documented radiographic evidence of the diagnosis (e.g., irregular joint surfaces, subchondral cysts, glenoid flattening or sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis)
  • Documentation of moderate-to-severe chronic pain OR chronic functional disability for a minimum of 12 weeks
  • Documentation of at least 12 weeks of unsuccessful conservative therapy. (If conservative therapy is not appropriate, the medical record must clearly document why such approach is not reasonable.)
  1. Treatment of acute proximal humerus fractures (PHFs) not amenable to conservative therapy or internal fixation
  2. Treatment of nonunion or malunion PHFs with radiographic evidence
  3. Reconstruction following tumor resection of the glenohumeral joint, proximal humerus, or adjacent tissue
  4. Massive irreparable rotator cuff tears (MIRCTs) when all the following are present:
  • Evidence of massive rotator cuff tear (MRCT) by magnetic resonance imaging (MRI) or arthroscopy (e.g., tear size greater than 5 cm in an anterior-posterior or medial-lateral orientation, or tears of two or more tendons, or retraction of the tendon to the glenoid rim with greater than 2/3 of the greater tuberosity exposed on imaging in the sagittal plane)
  • Pseudo-paralysis
  • Documentation of at least 12 weeks of unsuccessful conservative therapy including 12 weeks of supervised physical therapy (PT). (If conservative therapy is not appropriate, the medical record must clearly document why such approach is not reasonable.)
  1. Reverse total shoulder arthroplasty (RTSA) following failed anatomic total shoulder arthroplasty (aTSA) or failed hemiarthroplasty (HA)

The scales used for measurement of pain or disability must be documented in the medical record. Acceptable scales include but are not limited to:

  • Verbal rating scales
  • Numerical Rating Scale (NRS) 
  • Visual Analog Scale (VAS) for pain assessment 
  • Disabilities of the Arm, Shoulder, and Hand (DASH)
  • Shoulder Pain and Disability Index (SPADI) 
  • American Shoulder and Elbow Surgeon score (ASES)
  • Simple Shoulder Test (SST) 
  • Constant-Murley score
  • Western Ontario Rotator Cuff Index (WORC)

Documentation must include unsuccessful conservative therapy, a pain or disability assessment performed and documented at baseline and after therapeutic intervention using the same scale for each assessment.

Conservative therapy: nonoperative treatment that may include 1 or more of the following:

  • Anti-inflammatory medications or analgesics
  • Flexibility and muscle strengthening exercises
  • A trial of supervised PT
  • Corticosteroid injections

The Medicare Program Integrity Manual states services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

Patient safety and quality-of-care mandate that healthcare professionals who perform shoulder arthroplasty are appropriately trained and/or credentialed by a formal residency/fellowship program, and/or are certified by either an accredited and nationally recognized organization, or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program whose core curriculum includes the performance and management of the procedures addressed in this LCD. Credentialing and privileges are required for procedures performed in inpatient and outpatient settings.

What to Include in the Medical Record to Avoid Denials

  • Relevant information addressing coverage criteria related to the beneficiary's episode of care
  • Correct beneficiary
  • Correct date of service
  • History and physical
  • Physician progress notes
  • Description of the pain (onset, duration, character, aggravating, and relieving factors)
  • Pain causing functional disability that interferes with Activities of Daily Living (ADLs) or pain that is increased with initiation of activities 
  • Safety issues 
  • Contraindications to non-surgical treatments
  • Listing, description, and outcomes of failed non-surgical treatments, such as:
     
    • Trial of medications (for example, Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Physical therapy and/or home exercise plans
    • Intra-articular injections
    • Assistive devices (for example, braces (specify type of brace), and orthotics)

Objective Findings to Include in the Physical Examination

  • Any deformity
  • Range of motion
  • Crepitus
  • Effusions
  • Tenderness
  • Include any test that were given (plain radiography and pre-operative imaging studies) 

Pre-Operative Documentation Should Include Specific Conditions

  • For patients with significant conditions or comorbidities, the risk/benefit of non-cardiac surgery, such as TSA should be appropriately documented in the medical record
  • Osteoarthritis (mild, moderate, severe)
  • Arthritis of the shoulder supported by X-ray or MRI 
  • Inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis)
  • Failure of previous osteotomy
  • Malignancy 
    • Pathology reports and referral from an oncologist
       
  • Avascular necrosis 
  • Fractures 
  • Nonunion, malunion proximal humerus fractures
  • MRCTs
  • Osteonecrosis
  • Laboratory and/or pathology reports
    • If infection involved above reports must be in medical record and all documentation regarding treatment of infection and a physician note indicating that it is appropriate to proceed with surgery

Post-Operative Documentation

  • Operative report for the procedure, including observed pathology
  • Daily progress notes for inpatients
  • Discharge summary, plan, and discharge orders

Resources 


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