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2025 CPT code 23552

Open treatment of acute or chronic acromioclavicular dislocation with fascial graft (includes obtaining graft).

Adhere to all applicable CPT coding guidelines, specifically those related to the Musculoskeletal System section.Accurate documentation is crucial for appropriate code selection and reimbursement.

Modifiers 50 (bilateral procedure), 51 (multiple procedures), 54 (surgical care only), 76 (repeat procedure by the same physician), and others may be applicable depending on the circumstances of the case. Consult the current CPT guidelines for appropriate modifier use.

Medical necessity for this procedure is established based on the patient’s clinical presentation, failed conservative management (if attempted), and the need to achieve stable reduction of the acromioclavicular joint.Documentation of significant pain, instability, and functional limitation should support the medical necessity.

The orthopedic surgeon is clinically responsible for performing this procedure. This includes pre-operative planning, obtaining informed consent, performing the surgery, managing the post-operative course, and ensuring appropriate wound healing and functional recovery.

IMPORTANT:23550 (Open treatment of acromioclavicular dislocation, acute or chronic; without fascial graft) should be used if no fascial graft is utilized.

In simple words: This code describes surgery to fix a separated shoulder joint (acromioclavicular joint). The doctor makes an incision, puts the joint back in place, uses a tissue graft to stabilize it, and may use pins or screws for support.The graft is taken from another area of the body during the same operation.

This CPT code, 23552, reports the open surgical treatment of an acute or chronic acromioclavicular (AC) joint dislocation.The procedure involves an open approach to the AC joint, reduction of the dislocation, and stabilization using a fascial graft. Obtaining the fascial graft is included in this code. Internal fixation (pins, screws, etc.) may be used in conjunction with the fascial graft.The code encompasses the incision, dissection, reduction of the dislocation, graft placement, fixation, and closure of the surgical site.

Example 1: A 35-year-old male sustains an acute acromioclavicular dislocation during a football game.Open reduction with internal fixation and fascial graft is performed to achieve stable reduction and long-term stability., A 60-year-old female presents with chronic AC joint instability secondary to a prior injury. Open reduction and internal fixation with a fascial graft is performed to address the instability and pain., A 22-year-old male experiences an acute AC joint dislocation that failed to reduce with closed methods. Open reduction and internal fixation are performed, incorporating a fascial graft for increased stability.

Preoperative and postoperative diagnostic imaging (X-rays), operative report detailing the surgical technique including type of fixation and source of fascial graft, and appropriate post-operative care documentation including pain management and physical therapy referrals.

** This code should only be reported when a fascial graft is used in the open reduction of an acromioclavicular dislocation.Any additional procedures performed (e.g., other soft tissue repair) should be coded separately.

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