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The procedure described by CPT® Code 23106 refers to an arthrotomy of the sternoclavicular joint, which involves a surgical opening of the joint to allow for a synovectomy. A synovectomy is the surgical removal of the synovial membrane, which is the lining of the joint that produces synovial fluid. This fluid is essential for lubricating the joint and facilitating smooth movement. However, in certain conditions such as rheumatoid arthritis or synovial proliferative disorders, the synovial tissue can become inflamed, leading to an overproduction of synovial fluid and resulting in joint effusion, which is an accumulation of fluid in the joint space. The sternoclavicular joint is the connection point between the sternum (breastbone) and the clavicle (collarbone), and it plays a crucial role in shoulder movement and stability. During the procedure, an incision is made over the sternoclavicular joint to access the joint capsule. The surgeon carefully dissects the surrounding soft tissues to expose the joint, allowing for exploration and assessment of any damage or disease present. If necessary, samples of the synovial tissue may be taken for laboratory analysis to further evaluate the condition of the joint. The synovial tissue is then resected to alleviate symptoms and improve joint function. After the procedure, the incisions are closed, and a dressing is applied to promote healing.
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The procedure described by CPT® Code 23106 is indicated for various conditions affecting the sternoclavicular joint. These may include:
The procedure for CPT® Code 23106 involves several key steps to ensure effective access and treatment of the sternoclavicular joint:
After the completion of the procedure, patients can expect specific post-operative care and recovery considerations. The surgical site will be monitored for signs of infection or complications. Patients may be advised to limit movement of the affected joint to facilitate healing and reduce the risk of re-injury. Pain management strategies will be discussed, and follow-up appointments will be scheduled to assess recovery progress and determine if further treatment is necessary. Rehabilitation exercises may also be recommended to restore joint function and strength as healing progresses.
| Short Descr | INCISION OF COLLARBONE JOINT | Medium Descr | ARTHRT GLENOHUMRL JT STRNCLAV JT W/SYNVCT W/WOBX | Long Descr | Arthrotomy; sternoclavicular joint, with synovectomy, with or without 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) | 1 - Statutory payment restriction for assistants at surgery applies 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) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 162 - Other OR therapeutic procedures on joints |
| 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. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 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.) | 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) |
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| Pre-1990 | Added | Code added. |
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