How To Use CPT Code 23440

CPT code 23440 describes the surgical procedure of resection or transplantation of the long tendon of the biceps to improve the stability of the shoulder joint. 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 23440?

CPT 23440 is a code used to describe the surgical procedure of resection or transplantation of the long tendon of the biceps. This procedure is performed to improve the stability of the shoulder joint. The provider surgically removes or relocates the damaged tendon to a new point of attachment on the humerus bone.

2. Official Description

The official description of CPT code 23440 is: ‘Resection or transplantation of long tendon of biceps.’

3. Procedure

During the procedure, the patient is appropriately prepped and anesthetized. The provider makes an incision in the skin and dissects through the subcutaneous tissue to access the shoulder joint and the long tendon of the biceps. The damaged tendon is then either resected or transplanted to a new location on the humerus bone. If transplantation is performed, the provider drills a hole in the bone and secures the tendon to the new attachment point. After ensuring there is no bleeding, the provider sutures the soft tissue layers and places the patient’s arm in a sling. This procedure aims to improve the stability of the shoulder joint.

4. Qualifying circumstances

CPT 23440 is performed on patients who require improvement in the stability of their shoulder joint. This procedure is typically indicated for individuals with shoulder instability or other conditions that affect the function of the long tendon of the biceps. The provider must assess the patient’s condition and determine the need for resection or transplantation of the tendon. It is important to note that not all patients with shoulder issues will require this specific procedure, and the decision to perform CPT 23440 should be based on the individual patient’s clinical presentation and medical history.

5. When to use CPT code 23440

CPT code 23440 should be used when the provider performs the surgical resection or transplantation of the long tendon of the biceps to improve the stability of the shoulder joint. It is important to accurately document the details of the procedure and ensure that it meets the criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 23440, the provider must document the following information:

• Patient’s diagnosis and indication for the procedure
• Details of the surgical technique used (resection or transplantation)
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed during the same session
• Any complications or unexpected findings
• Post-operative care instructions
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 23440, it is important to ensure that the documentation supports the performance of the resection or transplantation of the long tendon of the biceps. This code should not be reported if other codes within the range of 23395-23491 are already performed in the previous seven days. It is also essential to follow any specific guidelines provided by the payer or coding guidelines to ensure accurate and appropriate billing.

8. Historical information

CPT 23440 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 23440

There are several similar codes to CPT 23440 within the range of repair, revision, and/or reconstruction procedures on the shoulder (23395-23491). These codes describe various surgical procedures performed on the shoulder joint, including repairs, revisions, and reconstructions. It is important to review the code descriptions and documentation requirements to accurately report the specific procedure performed.

9. Examples

1. A patient with recurrent shoulder dislocations undergoes resection of the long tendon of the biceps to improve joint stability.
2. A professional athlete with a torn biceps tendon undergoes transplantation of the tendon to a new attachment point on the humerus bone.
3. A patient with chronic shoulder pain and instability undergoes resection of the damaged long tendon of the biceps to alleviate symptoms and improve joint function.
4. An individual with a history of shoulder dislocation and subluxation undergoes transplantation of the long tendon of the biceps to enhance joint stability.
5. A patient with a traumatic injury to the shoulder joint undergoes resection of the damaged biceps tendon to restore stability and function.
6. An elderly individual with degenerative changes in the shoulder joint undergoes transplantation of the long tendon of the biceps to improve joint stability and alleviate pain.
7. A patient with a history of failed conservative treatment for shoulder instability undergoes resection of the long tendon of the biceps as a surgical intervention.
8. A young athlete with a partial tear of the biceps tendon undergoes transplantation of the tendon to a new attachment point to prevent further damage and improve joint stability.
9. A patient with chronic shoulder instability and recurrent subluxations undergoes resection of the long tendon of the biceps to address the underlying cause of the instability.
10. An individual with a history of shoulder dislocation and persistent pain undergoes transplantation of the long tendon of the biceps to enhance joint stability and alleviate symptoms.