How To Use CPT Code 23415

CPT code 23415 describes a procedure called coracoacromial ligament release, which is performed to restore shoulder function in patients experiencing a stiff, painful, or frozen shoulder. 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 23415?

CPT code 23415 is used to describe a surgical procedure known as coracoacromial ligament release. This procedure is performed to restore shoulder function in patients who are experiencing a stiff, painful, or frozen shoulder. The provider may also perform acromioplasty, which involves shaving a portion of the bone from the underside of the acromion process to relieve abnormal pressure on underlying muscle or tendon.

2. Official Description

The official description of CPT code 23415 is: ‘Coracoacromial ligament release, with or without acromioplasty. (For arthroscopic procedure, use 29826)’

3. Procedure

During the coracoacromial ligament release procedure, the provider begins by making an incision on the outer side of the shoulder, in line with the deltoid muscle fibers. They then dissect through the subcutaneous tissue, or just under the skin, and retract the muscles, blood vessels, and nerves to expose the coracoacromial ligament. The provider then performs micro dissection to release the ligament from the acromion process. If necessary, they may also perform acromioplasty, using a surgical burr to shave off a portion of bone from the underside of the acromion process. This relieves pressure on the underlying structures and alleviates pain in the shoulder joint. Finally, the provider stops any bleeding, irrigates the surgical site, and closes the wound by suturing the layers of tissue together.

4. Qualifying circumstances

CPT code 23415 is used for patients who have a stiff, painful, or frozen shoulder and require a coracoacromial ligament release procedure. This procedure is typically performed when conservative treatments, such as physical therapy or medication, have failed to provide relief. The patient must meet the criteria for the procedure, as determined by the provider, and have a documented medical necessity for the surgery.

5. When to use CPT code 23415

CPT code 23415 should be used when a provider performs a coracoacromial ligament release procedure, with or without acromioplasty, to restore shoulder function in patients with a stiff, painful, or frozen shoulder. It is important to note that this code is specifically for open procedures. If the procedure is performed arthroscopically, CPT code 29826 should be used instead.

6. Documentation requirements

To support a claim for CPT code 23415, the provider must document the following information:

• Patient’s diagnosis and the medical necessity for the coracoacromial ligament release procedure
• Details of the procedure performed, including whether acromioplasty was also performed
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Post-operative care instructions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 23415, it is important to ensure that the procedure performed matches the description of the code. The provider should also ensure that the documentation supports the medical necessity for the procedure. Additionally, it is important to follow any specific billing guidelines provided by the payer or insurance company.

8. Historical information

CPT code 23415 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 23415

There are several similar codes to CPT code 23415 that may be used for related procedures. These include:

• CPT 23410: Subacromial decompression
• CPT 23412: Excision of the distal clavicle
• CPT 23420: Removal of the coracoid process
• CPT 23430: Tenotomy, biceps tendon, proximal
• CPT 23440: Tenotomy, biceps tendon, distal

9. Examples

1. A patient with a frozen shoulder undergoes a coracoacromial ligament release procedure to restore shoulder function.
2. A patient with chronic shoulder pain undergoes a coracoacromial ligament release procedure with acromioplasty to relieve pressure on underlying structures.
3. A patient with a stiff shoulder undergoes a coracoacromial ligament release procedure to improve range of motion.
4. A patient with a painful shoulder due to impingement undergoes a coracoacromial ligament release procedure to alleviate symptoms.
5. A patient with a rotator cuff tear undergoes a coracoacromial ligament release procedure as part of their surgical treatment plan.
6. A patient with a history of shoulder dislocations undergoes a coracoacromial ligament release procedure to stabilize the joint.
7. A patient with shoulder osteoarthritis undergoes a coracoacromial ligament release procedure to improve joint function.
8. A patient with a shoulder injury undergoes a coracoacromial ligament release procedure to repair damaged structures.
9. A patient with a shoulder impingement syndrome undergoes a coracoacromial ligament release procedure to relieve pressure on the rotator cuff.
10. A patient with a shoulder labral tear undergoes a coracoacromial ligament release procedure as part of their surgical treatment plan.