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2025 CPT code 73040

Radiologic examination of the shoulder joint using arthrography; includes radiological supervision and interpretation.

Follow current CPT coding guidelines for radiology procedures, paying attention to the distinction between professional and technical components.Modifiers may be required in certain circumstances.

Modifiers 26 (professional component only) and 52 (reduced services) may be appended in certain situations, such as when the interpretation is performed by a different provider than the one who supervised the procedure.

Medical necessity for a shoulder arthrogram is established when other less invasive imaging modalities (such as ultrasound or plain radiographs) are insufficient to adequately assess the shoulder joint structures, especially in cases of suspected rotator cuff tears, labral tears, or other intra-articular pathology. The procedure must be deemed medically appropriate by the referring physician. Specific payer requirements may need to be considered.

The radiologist is responsible for the supervision of the arthrogram injection procedure, image acquisition, and interpretation of the resulting images.

IMPORTANT:Code 77002 (Fluoroscopic guidance for needle placement) may be reported in addition to 73040 if fluoroscopy is used to guide the injection.If a CT or MRI arthrogram is performed following contrast injection, codes 73201, 73222, or others may be applicable instead of, or in addition to, 73040, depending on the imaging modality and use of contrast. Code 23350 (Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography) may be used for the injection procedure itself.

In simple words: This code covers an X-ray exam of your shoulder joint after a special dye or air is injected. The doctor watches the procedure, takes the X-rays, and examines them to check for problems like arthritis or tears.

This CPT code encompasses the radiologic examination of the shoulder joint via arthrography.The procedure involves the injection of contrast material and/or air into the shoulder joint, followed by a series of X-rays to visualize the joint structures. The radiologist's responsibilities include supervision of the injection procedure, acquisition of the images, and interpretation of the resulting radiographs to evaluate for conditions such as arthritis, adhesive capsulitis, tears, or cartilage abnormalities.The code specifically covers the professional component (interpretation and supervision) and excludes the technical component (image acquisition).

Example 1: A patient presents with shoulder pain and suspected rotator cuff tear. An arthrogram is performed to visualize the joint structures and confirm the diagnosis.The radiologist supervises the injection, acquires the images, and interprets the findings., A patient with chronic shoulder pain undergoes an arthrogram to evaluate for arthritis. The radiologist guides the injection under fluoroscopy, obtains the images, and interprets the findings to assess the severity of the arthritis., A patient with a history of shoulder dislocation undergoes an arthrogram to assess joint stability. The procedure is performed under fluoroscopic guidance. The radiologist interprets the images to determine the extent of any joint damage.

*Detailed history and physical examination of the shoulder.*Pre-procedure consent.*Radiology reports with interpretation of images.*Documentation of the type and amount of contrast material used.*Images from all views obtained during the procedure.*Any complications encountered.

** This code should only be reported when a complete arthrogram is performed, including contrast injection and multiple X-ray views.If only a few images are taken to confirm needle placement, a different code may be more appropriate.

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