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The glenohumeral joint, commonly referred to as the shoulder joint, is a critical component of the shoulder complex, which consists of three primary joints: the glenohumeral joint, the sternoclavicular joint, and the acromioclavicular joint. The glenohumeral joint is characterized as a shallow ball-and-socket joint, formed by the articulation of the glenoid fossa of the scapula and the head of the humerus. This joint allows for a wide range of motion in the shoulder, making it essential for various upper limb activities. The procedure described by CPT® Code 23100 involves an arthrotomy of the glenohumeral joint, which includes an open biopsy. During this procedure, a surgical incision is made over the deltoid and pectoral muscles to access the joint. The muscles are carefully divided, and the subscapularis tendon is split to reveal the joint capsule. Once the capsule is incised, the surgeon can explore the joint for any signs of disease, injury, or abnormalities. Tissue samples are collected from the joint cavity for further laboratory analysis, which is crucial for diagnosing potential conditions affecting the joint. After the exploration and biopsy are completed, the incisions are meticulously closed, and a dressing is applied to promote healing.
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The procedure described by CPT® Code 23100 is indicated for various conditions affecting the glenohumeral joint. These may include:
The procedure for CPT® Code 23100 involves several critical steps to ensure proper access and evaluation of the glenohumeral joint. The steps are as follows:
Following the arthrotomy and biopsy of the glenohumeral joint, patients can expect specific post-procedure care and considerations. It is essential to monitor the surgical site for any signs of infection, such as increased redness, swelling, or discharge. Pain management may be necessary, and patients are typically advised to follow a rehabilitation program to restore shoulder function gradually. The recovery period may vary depending on the extent of the procedure and the individual patient's health status. Patients should also be informed about the importance of follow-up appointments to discuss laboratory results and any further treatment options based on the findings from the biopsy.
| Short Descr | BIOPSY OF SHOULDER JOINT | Medium Descr | ARTHROTOMY GLENOHUMERAL JOINT W/BIOPSY | Long Descr | Arthrotomy, glenohumeral joint, including biopsy | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 1 | CCS Clinical Classification | 159 - Other diagnostic procedures on musculoskeletal system |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| Pre-1990 | Added | Code added. |
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