2025 CPT code 23107

Arthrotomy of the glenohumeral joint with exploration, with or without removal of loose or foreign body.

The CPT guidelines state that the application and removal of the first cast, splint, or traction device are included in musculoskeletal system codes. Separate reporting for subsequent replacements during or after the global period is permissible.Casting/splinting for temporary stabilization is not considered closed treatment.

Modifiers may be applicable.Modifier 54 is used if the surgeon performing the procedure will not be providing subsequent care.Modifiers 76 and 77 are utilized for repeat procedures by the same or a different surgeon, respectively.Modifiers, like 22 (increased procedural services), 52 (reduced services), and 53 (discontinued procedure) can be applied based on circumstances.

Medical necessity must be established by demonstrating the clinical rationale for the procedure. This can be through documented symptoms, functional limitations, failed conservative treatments, and supporting diagnostic evidence indicating a loose body or foreign object within the glenohumeral joint.

The surgeon prepares the patient and administers anesthesia. An incision is made over the glenohumeral joint, extending to the joint capsule. After opening the capsule, the surgeon examines the joint's structures and removes loose bodies or foreign objects. The area is then irrigated, bleeding is controlled, instruments are removed, and the incision is closed.

In simple words: The surgeon makes an incision in your shoulder to open the joint and inspect it. They might remove loose pieces or foreign objects inside the joint. This is done to relieve pain and improve mobility.

The procedure involves surgically opening the glenohumeral joint (shoulder joint) to explore the internal structures. This may include removing any loose fragments or foreign bodies present within the joint.

Example 1: A patient presents with persistent shoulder pain and limited range of motion following a fall. Imaging reveals a possible loose body within the glenohumeral joint. CPT code 23107 is used for the arthrotomy and exploration of the joint to remove the loose body., A patient experiences shoulder pain and clicking after a sports injury. Diagnostic tests suggest a torn piece of cartilage within the shoulder joint. Code 23107 applies to the surgical exploration of the glenohumeral joint and removal of the cartilage fragment., A patient has a history of recurrent shoulder dislocations and now has persistent pain and instability. Imaging reveals no specific abnormalities, but the physician suspects the presence of a loose or foreign body within the joint. Code 23107 covers the arthrotomy to explore the joint and address any loose or foreign material found.

Documentation should include details of the patient's history, physical examination findings, imaging results, operative report (describing the surgical findings and procedures performed), and any pathology reports if tissue was removed.

  • Specialties:Orthopedic Surgery, Sports Medicine
  • Place of Service:Ambulatory Surgical Center, Hospital - Inpatient, Hospital - Outpatient
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