How To Use CPT Code 23000

CPT 23000 describes the removal of subdeltoid calcareous deposits from the shoulder area through an open procedure. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 23000?

CPT 23000 is used to describe the excision of calcium deposits from the shoulder area, specifically the subdeltoid region. This procedure is performed through an open approach, involving making an incision in the deltoid muscle near the shoulder to access and remove the calcareous deposits.

2. Official Description

The official description of CPT code 23000 is: ‘Removal of subdeltoid calcareous deposits, open.’

3. Procedure

The procedure for CPT 23000 involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes a vertical incision through the skin and between the fibers of the deltoid muscle.
3. The incision is carried through the fascia beneath the deltoid to access the subdeltoid region.
4. A small opening is made in the subdeltoid bursa, which is a fluid-filled sac that prevents rubbing between joints, muscles, and tendons.
5. The opening in the bursa is enlarged to provide access to the calcareous deposits.
6. The provider excises the calcium deposits from the subdeltoid region.
7. The provider ensures that the patient’s range of motion is stable.
8. The area is irrigated, checked for bleeding, and any instruments are removed.
9. The incision is closed, and the patient’s arm is placed in a sling for support.

4. Qualifying circumstances

CPT 23000 is performed on patients who have subdeltoid calcareous deposits resulting from prior injuries. These deposits are composed of calcium carbonate. The procedure is indicated when the deposits cause symptoms or limit the patient’s range of motion, and conservative treatments have been ineffective. The patient must meet the medical necessity criteria for the procedure, as determined by the provider.

5. When to use CPT code 23000

CPT code 23000 should be used when a provider performs an open excision of subdeltoid calcareous deposits from the shoulder area. It is important to ensure that the procedure meets the specific criteria outlined in the code description and is medically necessary for the patient’s condition.

6. Documentation requirements

To support a claim for CPT 23000, the provider must document the following information:

• Patient’s diagnosis and symptoms related to the subdeltoid calcareous deposits
• Details of the procedure, including the incision site, approach, and technique used
• Confirmation of the patient’s range of motion stability post-procedure
• Irrigation and hemostasis of the surgical site
• Removal of instruments and closure of the incision
• Placement of the patient’s arm in a sling for support

7. Billing guidelines

When billing for CPT 23000, ensure that the procedure performed meets the specific criteria outlined in the code description. It is important to accurately document the details of the procedure and provide any necessary supporting documentation to justify medical necessity. CPT code 23000 should not be reported with other codes unless there are distinct and separate procedures performed during the same session.

8. Historical information

CPT 23000 was added to the Current Procedural Terminology system on January 1, 1990. There have been historical changes to the code, including a code change on January 1, 2002, which revised the description to specify the removal of subdeltoid (or intratendinous) calcareous deposits by any method.

9. Examples

1. A patient with a history of shoulder injuries presents with severe pain and limited range of motion due to subdeltoid calcareous deposits. The provider performs an open excision of the deposits using CPT code 23000.
2. A professional athlete sustains a shoulder injury and develops subdeltoid calcareous deposits. The provider performs an open removal of the deposits to restore the athlete’s range of motion and alleviate pain, utilizing CPT code 23000.
3. A patient with chronic shoulder pain and restricted movement undergoes diagnostic imaging, which reveals subdeltoid calcareous deposits. The provider recommends and performs an open excision of the deposits using CPT code 23000 to improve the patient’s symptoms.
4. A patient with a history of shoulder trauma experiences persistent discomfort and limited shoulder mobility due to subdeltoid calcareous deposits. The provider performs an open removal of the deposits using CPT code 23000 to alleviate the patient’s symptoms and improve function.
5. A middle-aged individual develops subdeltoid calcareous deposits following a shoulder injury. The provider performs an open excision of the deposits using CPT code 23000 to relieve pain and restore the patient’s range of motion.
6. A patient with a history of shoulder dislocation experiences ongoing pain and stiffness due to subdeltoid calcareous deposits. The provider performs an open removal of the deposits using CPT code 23000 to alleviate the patient’s symptoms and improve shoulder function.
7. An elderly individual with chronic shoulder pain and limited mobility is diagnosed with subdeltoid calcareous deposits. The provider recommends and performs an open excision of the deposits using CPT code 23000 to improve the patient’s quality of life and restore shoulder function.
8. A patient involved in a motor vehicle accident sustains a shoulder injury and subsequently develops subdeltoid calcareous deposits. The provider performs an open removal of the deposits using CPT code 23000 to alleviate pain and improve the patient’s range of motion.