How To Use CPT Code 23400

CPT code 23400 describes a surgical procedure known as scapulopexy. 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 23400?

CPT 23400 is a code used to describe the surgical procedure known as scapulopexy. Scapulopexy involves attaching the patient’s scapula (shoulder blade) to a rib or vertebra to correct shoulder asymmetries or deformities that create issues with the patient’s motion. This procedure is commonly performed for conditions such as Sprengel’s deformity, a congenital deformity in which one shoulder blade sits higher on the back than the other.

2. Official Description

The official description of CPT code 23400 is: ‘Scapulopexy (eg, Sprengel’s deformity or for paralysis).’ This code encompasses the surgical procedure of attaching the scapula to a rib or vertebra to correct shoulder deformities or asymmetries.

3. Procedure

During a scapulopexy procedure, the healthcare provider performs the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes a linear oblique skin incision on the inner border of the scapula.
3. The trapezius muscle is incised.
4. The rhomboid and elevator scapulae muscles are detached from the vertebral border of the scapula.
5. The rotator cuff muscles and serratus anterior muscles are released from the vertebral border of the scapula.
6. A small portion of the scapula is exposed, and the corresponding ribs are prepared.
7. A double metal wire is passed under each rib.
8. The scapula is placed over the rib cage in its definitive position.
9. Small holes are drilled opposite the prepared ribs, and one end of each wire is passed through the adjacent hole of the inner border of the scapula.
10. The metal wires are tightened to achieve bone-to-bone contact between the scapula and the ribs.
11. All bleeding is stopped, and the wound is closed by suturing the layers of tissue together.

4. Qualifying circumstances

Scapulopexy is performed for patients with conditions such as Sprengel’s deformity or paralysis that require surgical correction of shoulder asymmetries or deformities. The procedure is typically performed by a qualified healthcare provider with expertise in orthopedic surgery or a related field.

5. When to use CPT code 23400

CPT code 23400 should be used when a scapulopexy procedure is performed to correct shoulder asymmetries or deformities. It is important to ensure that the procedure meets the specific criteria outlined in the code description, such as being performed for Sprengel’s deformity or paralysis.

6. Documentation requirements

To support a claim for CPT code 23400, the healthcare provider must document the following information:

• Patient’s diagnosis, such as Sprengel’s deformity or paralysis
• Description of the procedure performed, including the specific steps taken
• Date of the procedure
• Any additional relevant details or complications encountered during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 23400, ensure that the procedure performed meets the specific criteria outlined in the code description. It is important to accurately document the diagnosis and procedure details to support the claim. Additionally, follow any specific billing guidelines provided by the payer or relevant coding guidelines.

8. Historical information

CPT code 23400 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 23400

There are several similar codes to CPT 23400 that may be used for related procedures. Some examples include:

• CPT 23405: Scapulopexy with bone graft
• CPT 23410: Scapulopexy with prosthetic implant
• CPT 23412: Scapulopexy with muscle transfer
• CPT 23420: Scapulopexy with joint capsule reconstruction
• CPT 23430: Scapulopexy with tendon transfer

9. Examples

Here are some examples of cases where CPT code 23400 may be billed:

1. A patient with Sprengel’s deformity undergoes scapulopexy to correct the asymmetry of their shoulder blades.
2. A patient with paralysis resulting in shoulder deformities undergoes scapulopexy to improve their range of motion and functional abilities.
3. A patient with a congenital shoulder deformity undergoes scapulopexy to correct the positioning of their scapula and improve their overall shoulder function.
4. A patient with a traumatic injury resulting in shoulder asymmetry undergoes scapulopexy to restore normal shoulder alignment and function.
5. A patient with a rare shoulder condition requiring surgical intervention undergoes scapulopexy to address their specific shoulder deformity.