How To Use CPT Code 23406

CPT code 23406 describes a procedure called multiple tenotomy in the shoulder area, where the provider incises or divides multiple tendons through the same incision in the skin. 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 23406?

CPT 23406 is a code used to describe a procedure called multiple tenotomy in the shoulder area. In this procedure, the provider makes a small incision in the skin of the shoulder over the tendons to be divided. The tendons are then incised to release and lengthen them, allowing the muscles to return to their normal length. This procedure is performed to correct painful conditions of the shoulder joint caused by congenital or acquired conditions.

2. Official Description

The official description of CPT code 23406 is: ‘Tenotomy, shoulder area multiple tendons through same incision.’

3. Procedure

During the multiple tenotomy procedure, the provider follows a specific set of steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes a small incision in the skin of the shoulder over the tendons to be divided.
3. The provider dissects down through the subcutaneous tissue to locate the tendons.
4. The tendons are incised to release and lengthen them.
5. The provider stops any bleeding at the surgical site and closes the wound by suturing the soft tissue in layers.

4. Qualifying circumstances

CPT 23406 is used for patients who have painful conditions of the shoulder joint caused by congenital or acquired conditions. The procedure is performed by a provider to correct these conditions by incising or dividing multiple tendons through the same incision in the skin.

5. When to use CPT code 23406

CPT code 23406 should be used when the provider performs a multiple tenotomy in the shoulder area, incising or dividing multiple tendons through the same incision in the skin. It is important to ensure that the procedure is performed for the appropriate indications and that the documentation supports the use of this code.

6. Documentation requirements

To support a claim for CPT 23406, the provider must document the following information:

• Patient’s diagnosis and the need for the multiple tenotomy procedure
• Details of the procedure, including the specific tendons incised or divided
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Details of the closure of the wound
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 23406, ensure that the procedure meets the criteria for this code. It is important to follow the specific documentation requirements and guidelines provided by the payer. Additionally, be aware of any bundling or unbundling issues and use appropriate modifiers if necessary.

8. Historical information

CPT 23406 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 23406

There are several similar codes to CPT 23406 that describe procedures related to the repair, revision, and/or reconstruction of the shoulder. Some examples include:

• CPT 23405: Tenotomy, shoulder area single tendon
• CPT 23410: Tenotomy, biceps tendon, proximal
• CPT 23412: Tenotomy, biceps tendon, distal
• CPT 23420: Tenotomy, rotator cuff, open
• CPT 23430: Tenotomy, rotator cuff, arthroscopic

9. Examples

1. A patient with a congenital condition causing shoulder pain undergoes a multiple tenotomy procedure to release and lengthen the tendons in the shoulder area.
2. A patient with an acquired condition, such as a rotator cuff tear, undergoes a multiple tenotomy procedure to correct the painful condition.
3. A provider performs a multiple tenotomy procedure on a patient with a history of shoulder dislocations to stabilize the joint and alleviate pain.
4. A patient with a congenital shortening of the muscles in the shoulder area undergoes a multiple tenotomy procedure to correct the deformity and relieve pain.
5. A provider performs a multiple tenotomy procedure on a patient with a history of shoulder impingement syndrome to alleviate pain and improve range of motion.
6. A patient with a traumatic injury to the shoulder undergoes a multiple tenotomy procedure to repair and lengthen the tendons affected by the injury.
7. A provider performs a multiple tenotomy procedure on a patient with a chronic inflammatory condition affecting the tendons in the shoulder area to alleviate pain and improve function.
8. A patient with a history of failed conservative treatments for shoulder pain undergoes a multiple tenotomy procedure as a last resort to relieve the pain and improve quality of life.
9. A provider performs a multiple tenotomy procedure on a patient with a congenital condition causing shoulder instability to stabilize the joint and prevent further dislocations.
10. A patient with a history of recurrent shoulder subluxations undergoes a multiple tenotomy procedure to correct the instability and alleviate pain.