How To Use CPT Code 23405

CPT code 23405 describes a procedure called tenotomy, which involves the incision or division of a single tendon in the shoulder area. 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 23405?

CPT 23405 is a code used to describe the tenotomy procedure performed by a healthcare provider in the shoulder area. During this procedure, the provider makes a small incision in the skin and divides a single tendon to correct painful conditions of the shoulder joint caused by congenital or acquired conditions.

2. Official Description

The official description of CPT code 23405 is: ‘Tenotomy, shoulder area single tendon.’

3. Procedure

During the tenotomy procedure, the healthcare provider first preps and anesthetizes the patient. Then, they make a small incision in the skin over the tendon that needs to be divided. The provider carefully dissects through the subcutaneous tissue to locate the tendon. Once the tendon is identified, they incise it to release and lengthen it. This allows the muscle to return to its normal length, correcting the deformity and relieving pain. The provider ensures that any bleeding at the surgical site is stopped and closes the wound by suturing the soft tissue layers.

4. Qualifying circumstances

CPT 23405 is used for patients who have painful conditions of the shoulder joint caused by congenital or acquired conditions. The procedure is performed by a healthcare provider to correct deformities and relieve pain. It is important to note that this code specifically applies to the division of a single tendon in the shoulder area.

5. When to use CPT code 23405

CPT code 23405 should be used when a healthcare provider performs a tenotomy procedure in the shoulder area, specifically involving the division of a single tendon. It is important to accurately document the procedure and ensure that it meets the criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 23405, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the tenotomy procedure
• Specific tendon that was divided
• Date of the procedure
• Details of the procedure, including the incision and division of the tendon
• Any additional procedures performed during the same session
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 23405, ensure that the procedure performed meets the criteria outlined in the code description. It is important to accurately document the procedure and any additional services provided during the same session. Follow the appropriate coding guidelines and modifiers, if applicable, to ensure accurate billing.

8. Historical information

CPT 23405 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Similar codes to CPT 23405

There are several similar codes to CPT 23405 that describe related procedures in the shoulder area. These include:

• CPT 23406: Tenotomy, shoulder area multiple tendons through the same incision
• CPT 23410: Tenotomy, biceps tendon, open (separate procedure)
• CPT 23412: Tenotomy, biceps tendon, percutaneous (separate procedure)
• CPT 23420: Tenotomy, triceps tendon, open (separate procedure)
• CPT 23430: Tenotomy, quadriceps or patellar tendon, open (separate procedure)

9. Examples

1. A healthcare provider performs a tenotomy procedure on a patient with congenital shortening of the biceps tendon in the shoulder area.
2. A patient with acquired tendonitis in the shoulder undergoes a tenotomy procedure to relieve pain and improve joint function.
3. A healthcare provider performs a tenotomy on a patient with a congenital deformity of the rotator cuff tendon in the shoulder.
4. A patient with a history of shoulder dislocation undergoes a tenotomy procedure to correct instability and prevent future dislocations.
5. A healthcare provider performs a tenotomy on a patient with a congenital shortening of the supraspinatus tendon in the shoulder area.
6. A patient with a rotator cuff tear undergoes a tenotomy procedure to release and lengthen the affected tendon, allowing for better healing and improved shoulder function.
7. A healthcare provider performs a tenotomy on a patient with a congenital shortening of the infraspinatus tendon in the shoulder area.
8. A patient with chronic shoulder pain undergoes a tenotomy procedure to address a tendon impingement and relieve symptoms.
9. A healthcare provider performs a tenotomy on a patient with a congenital shortening of the teres major tendon in the shoulder area.
10. A patient with a history of shoulder instability undergoes a tenotomy procedure to tighten and stabilize the affected tendon.