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2025 CPT code 23466

Capsulorrhaphy of the glenohumeral joint for multidirectional instability.

Follow current CPT coding guidelines for surgical procedures. Accurate documentation is crucial for proper code selection and reimbursement. Use appropriate modifiers where applicable (e.g., 51 for multiple procedures).

Modifiers may be applicable depending on the circumstances of the procedure. For example, modifier 51 might be used if multiple procedures are performed on the same day, and modifier 76 if the procedure is a repeat of a previously performed procedure by the same physician.

Medical necessity for capsulorrhaphy is established by documentation of persistent shoulder instability and symptoms despite conservative management, including physical therapy and other non-surgical interventions.The patient must exhibit significant functional limitations due to the instability.

The orthopedic surgeon or qualified specialist performs the capsulorrhaphy, addressing the laxity in the shoulder joint capsule and associated structures. This may involve arthroscopic or open techniques, along with repair of any associated labral tears.

In simple words: This surgery repairs and tightens the tissues around the shoulder joint to fix instability. It's used when the shoulder pops out of place easily, often improving stability and reducing pain.

Capsulorrhaphy of the glenohumeral joint involves surgical repair and tightening of the shoulder joint capsule to address multidirectional instability (MDI).The procedure aims to restore stability to the shoulder by addressing laxity in the ligaments and capsule surrounding the glenohumeral joint. This may involve various techniques to plicate or repair the capsule, often addressing associated labral tears as well.The approach can be open or arthroscopic.

Example 1: A 25-year-old female volleyball player experiences recurrent shoulder subluxations.After conservative management fails, a capsulorrhaphy is performed to stabilize the glenohumeral joint., A 30-year-old male baseball pitcher presents with chronic shoulder pain and instability due to multidirectional instability.Arthroscopic capsulorrhaphy is performed to tighten the joint capsule and address any associated labral tears., A 40-year-old female patient with a history of previous shoulder dislocation experiences persistent instability and pain despite physical therapy. Open capsulorrhaphy is performed, addressing significant capsular laxity.

** The description of capsulorrhaphy may include additional procedures like labral repair, which should be coded separately if performed.Always refer to the most current CPT manual and payer guidelines for accurate coding and reimbursement.

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