How To Use CPT Code 23130

CPT code 23130 describes the surgical procedure known as acromioplasty or acromionectomy, which involves reshaping the acromion, a bony projection at the end of the shoulder blade. 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 23130?

CPT 23130 is used to describe the surgical procedure of acromioplasty or acromionectomy. This procedure involves reshaping the acromion, which is the bony projection at the end of the shoulder blade. The purpose of this surgery is to restore motion to the shoulder and protect the rotator cuff. The provider may partially remove the acromion and/or incise the coracoacromial ligament, which attaches the muscle to the shoulder blade.

2. Official Description

The official description of CPT code 23130 is: ‘Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release.’

3. Procedure

1. The patient is appropriately prepped and anesthetized for the procedure.
2. The provider makes a sharp incision from the center of the acromioclavicular (AC) joint inferiorly, or downward.
3. The provider dissects through the skin and subcutaneous tissues down to the deltoid muscle.
4. The deltoid fibers are incised in line with the clavicle, and the dissection is extended to split the deltoid up to the dorsal aspect of the acromion.
5. The provider detaches the deltoid from the acromion subperiosteally to split and expose the anterior part of the acromion from the lateral corner to the AC joint.
6. The acromion is reshaped, and if necessary, the coracoacromial ligament is released.
7. To protect the rotator cuff, the provider makes a vertical cut with an osteotome or bone saw and resects the anterior acromion.
8. The corner of the acromion is excised anteroinferiorly with an osteotome to create a flat or slightly angled up acromion.
9. The area is irrigated, checked for bleeding, and any instruments are removed.
10. The incision is closed.

4. Qualifying circumstances

CPT 23130 is performed on patients who require acromioplasty or acromionectomy to restore motion to the shoulder and protect the rotator cuff. This procedure is typically performed on patients with conditions such as impingement syndrome or rotator cuff tears. The decision to perform this surgery is made by the provider based on the patient’s symptoms, physical examination, and imaging studies.

5. When to use CPT code 23130

CPT code 23130 should be used when the provider performs a partial acromioplasty or acromionectomy with or without coracoacromial ligament release. This code is appropriate when the procedure is performed to address specific shoulder conditions and restore shoulder function.

6. Documentation requirements

To support a claim for CPT 23130, the provider must document the following information:

• Patient’s diagnosis and the need for acromioplasty or acromionectomy
• Details of the procedure performed, including whether it was a partial acromioplasty or acromionectomy and whether coracoacromial ligament release was performed
• Date of the procedure
• Any additional findings or procedures performed during the surgery
• Post-operative instructions or recommendations
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 23130, ensure that the procedure performed meets the criteria for acromioplasty or acromionectomy. It is important to accurately document the details of the procedure and any additional findings or procedures performed. CPT code 23130 should not be reported with other codes that describe different procedures or services. It is important to follow the specific guidelines provided by the payer when submitting claims for CPT 23130.

8. Historical information

CPT code 23130 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. Examples

1. A patient with impingement syndrome undergoes a partial acromioplasty to relieve compression on the rotator cuff.
2. A patient with a rotator cuff tear undergoes an acromionectomy to protect the remaining rotator cuff and restore shoulder function.
3. A patient with chronic shoulder pain undergoes a partial acromioplasty with coracoacromial ligament release to address impingement and improve shoulder mobility.
4. A patient with a history of shoulder instability undergoes an acromionectomy to prevent recurrent dislocations.
5. A patient with a large acromial spur undergoes a partial acromioplasty to remove the bony prominence and alleviate impingement symptoms.
6. A patient with a history of shoulder trauma undergoes an acromionectomy to address post-traumatic deformity and restore shoulder function.