2025 CPT code 23462
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Shoulder Musculoskeletal System Feed
Anterior shoulder capsulorrhaphy with coracoid process transfer.
Modifiers may be applicable depending on the circumstances of the procedure such as 51 (multiple procedures), 59 (distinct procedural service), or 76 (repeat procedure).
Medical necessity is established by the presence of significant shoulder instability or hyperlaxity causing pain, functional impairment, or recurrent dislocations, unresponsive to conservative management.
The orthopedic surgeon is responsible for the entire procedure, including pre-operative planning, intra-operative technique, and post-operative care.
In simple words: The doctor repairs a tear in the shoulder joint's lining and tightens it if it's too loose. They also move a small bone projection (coracoid process) to make the shoulder more stable. This helps fix shoulder instability.
This procedure involves the surgical repair (capsulorrhaphy) of a torn anterior shoulder joint capsule.The procedure also includes tightening of the joint capsule to address hyperlaxity (excessive joint movement) and transferring the coracoid process to enhance shoulder stability.The surgeon incises the skin over the shoulder joint, dissects through subcutaneous tissue to expose the joint capsule, transects the subscapularis tendon, explores and assesses the capsule, irrigates the area to remove loose bodies, performs a vertical capsular division, places stay sutures, tightens the capsule, and transects and transfers the coracoid process to the glenoid rim. Hemostasis and wound closure are then completed.
Example 1: A 25-year-old patient presents with recurrent anterior shoulder dislocations.The surgeon performs a 23462 to address multidirectional instability., A 30-year-old athlete with a history of traumatic anterior shoulder instability undergoes a 23462 to repair a capsular tear and improve joint stability for return to sports., A 40-year-old patient with chronic shoulder pain and instability due to hyperlaxity undergoes a 23462 procedure for improved function and pain relief.
Preoperative diagnosis of shoulder instability, including imaging studies (X-rays, MRI, CT scans) showing the tear or hyperlaxity. Operative report detailing the surgical technique, including the transfer of the coracoid process. Postoperative imaging studies to assess the reduction and stability of the shoulder.Physical therapy notes demonstrating progress toward functional recovery.
** This code may be used in conjunction with other codes for additional procedures that may be performed during the same operative session.
- Payment Status: Active
- Modifier TC rule: A Technical Component (TC) modifier is likely not applicable to this code as it's a surgical procedure primarily performed by the surgeon.
- Specialties:Orthopedic Surgery
- Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Office