How To Use CPT Code 23040

CPT code 23040 describes the procedure of arthrotomy, specifically for the glenohumeral joint. 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 23040?

CPT 23040 is a code used to describe the surgical procedure of arthrotomy for the glenohumeral joint. This procedure involves making an incision in the shoulder joint to inspect the interior, drain any fluid, and remove any foreign bodies. It is typically performed in cases of recurrent dislocations or traumatic injuries.

2. Official Description

The official description of CPT code 23040 is: ‘Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body.’

3. Procedure

During the arthrotomy procedure, the patient is appropriately prepped and anesthetized. The healthcare provider makes a proximal incision over the glenohumeral joint and uses microdissection techniques to visualize the joint capsule. The provider then assesses the joint for any abnormalities, such as abscesses or fluid accumulation. If present, these are drained to alleviate the infection or inflammation. Additionally, any foreign bodies, such as bone fragments or shards of metal, are identified and removed. The area is then irrigated with antibiotics to prevent infection, checked for bleeding, and any instruments used are removed. Finally, the incision is closed.

4. Qualifying circumstances

CPT 23040 is typically performed in cases of recurrent dislocations or traumatic injuries to the glenohumeral joint. It is important to note that this procedure is specific to the glenohumeral joint and should not be used for other joints. The patient must meet the criteria for the procedure, and the healthcare provider must determine that an arthrotomy is necessary to address the patient’s condition.

5. When to use CPT code 23040

CPT code 23040 should be used when a healthcare provider performs an arthrotomy procedure on the glenohumeral joint. It is important to ensure that the procedure is specifically for the glenohumeral joint and not for other joints. This code should be used when the provider performs exploration, drainage, or removal of foreign bodies during the arthrotomy.

6. Documentation requirements

To support a claim for CPT 23040, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for arthrotomy
• Details of the procedure performed, including exploration, drainage, or removal of foreign bodies
• Date of the procedure
• Start and end time of the procedure
• Any complications or unexpected findings during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 23040, it is important to ensure that the procedure performed is specifically for the glenohumeral joint. This code should not be reported for procedures performed on other joints. Additionally, it is important to follow any specific billing guidelines provided by the payer or insurance company. It is also important to review any bundling or unbundling rules that may apply to this code.

8. Historical information

CPT 23040 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 23040

There are several similar codes to CPT 23040 that describe procedures on the shoulder joint. These include:

• CPT 23030: Arthrotomy, acromioclavicular joint
• CPT 23035: Arthrotomy, sternoclavicular joint
• CPT 23044: Arthrotomy, scapulothoracic joint
• CPT 23410: Arthrotomy, shoulder joint, with capsular repair
• CPT 23412: Arthrotomy, shoulder joint, with rotator cuff repair

9. Examples

1. A patient with recurrent shoulder dislocations undergoes an arthrotomy of the glenohumeral joint to explore and repair any damaged structures.
2. A patient with a traumatic injury to the shoulder undergoes an arthrotomy to drain an abscess and remove foreign bodies.
3. A patient with chronic shoulder pain undergoes an arthrotomy to explore the joint and identify any abnormalities causing the pain.
4. A patient with a history of shoulder dislocations undergoes an arthrotomy to remove a bone fragment causing impingement.
5. A patient with an infection in the shoulder joint undergoes an arthrotomy to drain the abscess and irrigate the area with antibiotics.
6. A patient with a foreign body lodged in the glenohumeral joint undergoes an arthrotomy to remove the foreign body and prevent further complications.
7. A patient with a history of shoulder trauma undergoes an arthrotomy to explore the joint and assess the extent of the damage.
8. A patient with a chronic inflammatory condition of the shoulder joint undergoes an arthrotomy to drain fluid and alleviate inflammation.
9. A patient with a suspected infection in the glenohumeral joint undergoes an arthrotomy to obtain a sample for culture and sensitivity testing.
10. A patient with a history of shoulder dislocations undergoes an arthrotomy to repair damaged ligaments and stabilize the joint.