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2025 CPT code 23395

Muscle transfer, any type, shoulder or upper arm; single.

Refer to CPT guidelines for specific coding instructions related to muscle transfers and musculoskeletal procedures.

Modifiers may be applicable depending on the specific circumstances of the procedure (e.g., 51 for multiple procedures, 76 for repeat procedures, etc.).

Medical necessity for this procedure should be established by documenting the functional impairment caused by the injury and the expected improvement in function following the muscle transfer.

The surgeon performs the muscle transfer, including dissecting the donor muscle, preparing the recipient site, positioning and fixing the muscle, irrigating the site, stopping bleeding, and closing the wound.

IMPORTANT:For multiple muscle transfers in the shoulder or upper arm, use code 23397.

In simple words: This procedure involves moving a muscle from one part of the body to the shoulder or upper arm to restore function lost due to injury. The surgeon carefully selects a suitable muscle, typically from the leg, and attaches it to the damaged area in the shoulder or upper arm to improve movement and strength.

This procedure involves transferring a muscle from another location of the patient's body to the shoulder or upper arm to treat injuries that impair upper extremity function due to muscle damage. The surgeon dissects a donor muscle (e.g., gracilis muscle) and prepares the recipient site in the shoulder or upper arm. The freed muscle is then positioned and fixed into place by suturing one end to the remaining damaged muscle and the other end to the bone. The site is irrigated, bleeding is stopped, and the wound is closed by suturing the layers of tissue together.

Example 1: A patient with a rotator cuff tear has significantly impaired shoulder function. A latissimus dorsi muscle transfer is performed to restore shoulder function., Following a brachial plexus injury, a patient experiences loss of elbow flexion. A gracilis muscle transfer is performed to restore elbow flexion., A patient with a traumatic biceps muscle rupture has weakness in elbow flexion and supination. A pectoralis major muscle transfer is performed to restore function.

Documentation should include details about the injury, the donor muscle used, the recipient site, the surgical technique employed, and any complications encountered. Preoperative and postoperative assessments of the patient's functional status should also be documented.

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