2025 CPT code 23415
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Musculoskeletal System Musculoskeletal System Feed
Release of the coracoacromial ligament, with or without acromioplasty.
Modifiers may apply depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 59 for distinct procedural service, 76 for a repeat procedure). Refer to the CPT manual for detailed modifier guidelines.
Medical necessity is established by the presence of significant shoulder pain, limited range of motion, and failure of conservative treatments. Imaging studies should demonstrate the need for surgical intervention.
The orthopedic surgeon performs the incision, dissection, ligament release, and acromioplasty (if performed). They also manage hemostasis, irrigation, and wound closure.
In simple words: The doctor cuts the coracoacromial ligament in the shoulder to fix pain and stiffness. They might also shave a small part of a nearby bone to ease pressure on muscles and tendons.This helps restore shoulder movement.
This procedure involves the surgical release of the coracoacromial ligament to alleviate shoulder pain and stiffness, often associated with conditions like a frozen shoulder.Acromioplasty, the shaving of a portion of the acromion process, may be performed concurrently to relieve pressure on underlying structures. The procedure begins with an incision along the deltoid muscle fibers, followed by dissection through subcutaneous tissue to expose the coracoacromial ligament.Microdissection is used to release the ligament from the acromion process. If acromioplasty is performed, a surgical burr is used to shave a portion of the acromion's undersurface. Hemostasis, irrigation, and wound closure complete the procedure.
Example 1: A 55-year-old female presents with a frozen shoulder, experiencing significant pain and limited range of motion.The surgeon performs a coracoacromial ligament release with acromioplasty to restore shoulder function., A 40-year-old male athlete suffers a shoulder impingement syndrome.The surgeon performs a coracoacromial ligament release to address the impingement and improve shoulder mobility., A 60-year-old patient with chronic shoulder pain undergoes a coracoacromial ligament release alone, without acromioplasty, due to a less severe condition.
Preoperative diagnosis and imaging (X-rays, MRI), operative report detailing the procedure performed (ligament release and/or acromioplasty), intraoperative photos, postoperative instructions, and follow-up notes.
** This code is used for open surgical release of the coracoacromial ligament.For arthroscopic procedures, a different code should be used (29826).
- Revenue Code: P3D (MAJOR PROCEDURE, ORTHOPEDIC - OTHER)
- Payment Status: Active
- Specialties:Orthopedic Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Office