How To Use CPT Code 23465

CPT code 23465 describes a surgical procedure known as capsulorrhaphy of the glenohumeral 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 23465?

CPT 23465 is a code used to describe a surgical procedure called capsulorrhaphy of the glenohumeral joint. This procedure involves repairing the capsule, or membrane covering, of the posterior shoulder joint to improve shoulder stability. It may be performed in conjunction with other shoulder surgeries in cases where the shoulder condition is severe.

2. Official Description

The official description of CPT code 23465 is: ‘Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block.’

3. Procedure

During the capsulorrhaphy procedure, the healthcare provider makes an incision over the shoulder joint after the patient is appropriately prepped and anesthetized. The posterior deltoid muscle is then split, followed by the horizontal splitting of the infraspinatus muscle. The provider moves the back and bottom portions of the joint capsule superiorly, or to the top, and shifts the superior portion inferiorly, or to the bottom. If the provider identifies a detachment of the capsule from the labrum, sutures may be passed through bone tunnels to reattach it. In some cases, a posterior glenoid bone graft may be performed as a bone block in addition to the posterior capsular shift. The area is then irrigated, checked for bleeding, instruments are removed, and the incision is closed.

4. Qualifying circumstances

CPT 23465 is typically performed on patients with severe shoulder instability or damage to the posterior shoulder joint capsule. It is important to note that this procedure is specific to the glenohumeral joint and should not be confused with sternoclavicular or acromioclavicular reconstruction, which have their own separate CPT codes (23530 and 23550, respectively).

5. When to use CPT code 23465

CPT code 23465 should be used when a healthcare provider performs a capsulorrhaphy procedure on the glenohumeral joint, specifically for the repair of the posterior shoulder joint capsule. It is important to ensure that the procedure is performed with or without a bone block, as indicated in the official description.

6. Documentation requirements

To support a claim for CPT code 23465, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for capsulorrhaphy of the glenohumeral joint
• Details of the procedure performed, including whether a bone block was used
• Date of the procedure
• Incision site and size
• Specific steps taken during the procedure, such as splitting the deltoid and infraspinatus muscles
• Any additional procedures performed in conjunction with the capsulorrhaphy
• Post-operative instructions and follow-up plans
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 23465, it is important to ensure that the procedure performed aligns with the official description. The use of a bone block should be clearly documented if applicable. It is also important to follow any specific guidelines provided by the payer regarding the use of this code. Additionally, it is important to note that CPT code 23465 should not be reported if sternoclavicular or acromioclavicular reconstruction procedures have already been performed in the previous seven days.

8. Historical information

CPT code 23465 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 23465

There are several similar codes to CPT 23465 that are used to describe other repair, revision, and/or reconstruction procedures on the shoulder. These codes include:

• CPT 23395: Repair of the shoulder joint capsule
• CPT 23410: Reconstruction of the shoulder joint
• CPT 23412: Revision of the shoulder joint
• CPT 23420: Reconstruction of the shoulder joint with tendon graft
• CPT 23430: Reconstruction of the shoulder joint with allograft

9. Examples

1. A patient with severe shoulder instability undergoes a capsulorrhaphy procedure on the glenohumeral joint to repair the posterior shoulder joint capsule.
2. A healthcare provider performs a capsulorrhaphy procedure with a bone block on a patient with recurrent shoulder dislocations.
3. A patient with a history of shoulder trauma undergoes a capsulorrhaphy procedure to improve shoulder stability and prevent further dislocations.
4. A healthcare provider performs a capsulorrhaphy procedure on a patient with chronic shoulder pain and instability.
5. A patient with a history of shoulder dislocations undergoes a capsulorrhaphy procedure to repair the damaged joint capsule and improve shoulder stability.
6. A healthcare provider performs a capsulorrhaphy procedure on a patient with a labral tear and shoulder instability.
7. A patient with a history of shoulder subluxations undergoes a capsulorrhaphy procedure to tighten the joint capsule and improve shoulder stability.
8. A healthcare provider performs a capsulorrhaphy procedure on a patient with multidirectional shoulder instability.
9. A patient with a history of shoulder dislocations due to ligament laxity undergoes a capsulorrhaphy procedure to tighten the joint capsule and improve shoulder stability.
10. A healthcare provider performs a capsulorrhaphy procedure on a patient with recurrent shoulder instability following a previous surgical repair.