How To Use CPT Code 23020

CPT code 23020 describes the release of a capsular contracture in the shoulder joint to improve range of motion in a stiff or frozen shoulder. 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 23020?

CPT 23020 is used to describe the surgical procedure of releasing a capsular contracture in the shoulder joint. This procedure is performed to improve the range of motion in a stiff or frozen shoulder. It involves making an incision over the pectoral muscle, removing the subscapularis tendon from the glenoid rim, detaching the pectoralis major tendon from the humerus, irrigating the area, and closing the incision.

2. Official Description

The official description of CPT code 23020 is: ‘Capsular contracture release (eg, Sever type procedure).’ This procedure involves releasing a contracture involving the joint capsule in the shoulder to improve range of motion in a stiff or frozen shoulder.

3. Procedure

When performing CPT 23020, the healthcare provider follows a specific procedure:

1. The patient is appropriately prepped and anesthetized.
2. An incision is made over the pectoral muscle.
3. The subscapularis tendon is removed from the glenoid rim, leaving the anterior capsule intact.
4. The pectoralis major tendon is detached from the humerus.
5. The area is irrigated and checked for bleeding.
6. Any instruments are removed, and the incision is closed.

4. Qualifying circumstances

CPT 23020 is performed on patients with a capsular contracture in the shoulder joint, resulting in limited range of motion. This procedure is indicated for patients with a stiff or frozen shoulder. It is important to note that this code specifically refers to the Sever type procedure for capsular contracture release in the shoulder.

5. When to use CPT code 23020

CPT code 23020 should be used when a healthcare provider performs a capsular contracture release in the shoulder joint to improve range of motion in a stiff or frozen shoulder. It is important to ensure that the procedure performed aligns with the specific requirements of CPT 23020.

6. Documentation requirements

To support a claim for CPT 23020, the healthcare provider must document the following information:

• Patient’s diagnosis of capsular contracture in the shoulder joint
• Procedure performed, including the specific steps taken
• Date of the procedure
• Incision site and size
• Details of any complications or unexpected findings
• Post-procedure instructions or recommendations
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 23020, ensure that the procedure performed aligns with the specific requirements of the code. It is important to follow the documentation requirements and provide accurate information to support the claim. There are no specific guidelines regarding reporting CPT 23020 with other codes.

8. Historical information

CPT 23020 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

Here are some examples of cases where CPT code 23020 may be used:

1. A patient with a stiff shoulder due to capsular contracture undergoes a Sever type procedure to release the contracture and improve range of motion.
2. A patient with a frozen shoulder undergoes a capsular contracture release to restore mobility in the joint.
3. A patient with limited range of motion in the shoulder joint due to a capsular contracture undergoes surgery to release the contracture and improve function.
4. A patient with chronic shoulder pain and restricted movement undergoes a Sever type procedure to release the capsular contracture and alleviate symptoms.
5. A patient with a history of shoulder trauma develops a capsular contracture and undergoes surgery to release the contracture and restore normal shoulder function.