2025 CPT code 23106

Arthrotomy of the sternoclavicular joint with synovectomy, including biopsy when performed.

Refer to CPT guidelines for specific instructions on coding procedures on the musculoskeletal system. The application and removal of the first cast, splint, or traction device are included in musculoskeletal system codes.

Modifiers may be applicable.Refer to current CPT guidelines for modifier usage.

Medical necessity is established by documenting the patient's symptoms, physical exam findings, imaging studies, and prior treatments.The documentation must support the need for surgical intervention to address the sternoclavicular joint condition, such as chronic pain, inflammation, or instability.

The surgeon prepares the patient and administers anesthesia. An incision is made over the sternoclavicular joint, and the underlying tissues are dissected to reach the joint capsule. The joint capsule is opened, and the synovium (joint lining) is partially or completely removed. If needed, a tissue sample is taken for biopsy. The incision is then closed after irrigating the area and controlling any bleeding.

In simple words: This procedure involves opening the shoulder joint where the collarbone meets the breastbone to remove inflamed tissue lining the joint.The doctor may also take a small tissue sample for analysis.

This code describes a surgical procedure where the sternoclavicular joint is opened (arthrotomy) to remove the synovial membrane (synovectomy).A biopsy may also be taken during the procedure. The sternoclavicular joint is where the collarbone (clavicle) meets the breastbone (sternum).

Example 1: A patient with rheumatoid arthritis experiencing pain and limited range of motion in their sternoclavicular joint undergoes a synovectomy to remove the inflamed synovium and improve joint function., A patient with sternoclavicular joint pain and swelling undergoes arthrotomy with synovectomy and biopsy to diagnose and treat a suspected infection., Following trauma to the sternoclavicular joint, a patient with persistent pain and instability undergoes synovectomy to address chronic inflammation and improve joint stability.

Documentation should include the operative report detailing the procedure, including the extent of synovectomy, whether a biopsy was performed, and any findings related to the joint condition.Preoperative and postoperative diagnoses, along with the medical necessity for the procedure, should also be documented.

  • Revenue Code: P3D
  • Payment Status: Active
  • Specialties:Orthopedic Surgery
  • Place of Service:Ambulatory Surgical Center, Outpatient Hospital, Inpatient Hospital
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