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Official Description

Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 23107 refers to an arthrotomy of the glenohumeral joint, which is the primary joint of the shoulder. This surgical intervention involves an open exploration of the joint to assess and address various conditions that may affect its function. 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. The purpose of this procedure is to investigate the joint for the presence of disease, injury, or other pathological conditions, including the identification and removal of loose or foreign bodies that may be causing pain or dysfunction. The surgical approach typically involves making an incision over the deltoid and pectoral muscles, allowing access to the joint capsule for thorough examination and treatment. This procedure is critical for diagnosing issues such as osteochondral defects, labral tears, and rotator cuff injuries, which can significantly impact a patient's mobility and quality of life.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The arthrotomy of the glenohumeral joint, as described by CPT® Code 23107, is indicated for various conditions that may compromise the integrity and function of the shoulder joint. The following are specific indications for performing this procedure:

  • Joint Disease The presence of degenerative joint disease or other pathological conditions affecting the glenohumeral joint.
  • Injury Traumatic injuries to the shoulder that may require direct visualization and intervention.
  • Loose or Foreign Bodies The suspicion or confirmation of loose bodies or foreign materials within the joint that may cause pain or mechanical symptoms.
  • Labral Tears Evaluation of potential tears in the anterior or posterior labrum that could lead to instability or pain.
  • Rotator Cuff Issues Assessment of rotator cuff integrity, including tears or inflammation of the associated tendons.

2. Procedure

The procedure for an arthrotomy of the glenohumeral joint involves several critical steps to ensure thorough exploration and treatment of the joint. The following outlines the procedural steps:

  • Step 1: Incision An anterior approach is utilized, where a skin incision is made over the deltoid and pectoral muscles to gain access to the shoulder joint.
  • Step 2: Muscle Division The deltoid and pectoral muscles are carefully divided to expose the underlying structures, allowing for better access to the joint capsule.
  • Step 3: Scapularis Tendon Splitting The scapularis tendon is split to further expose the glenohumeral joint capsule, facilitating direct visualization of the joint.
  • Step 4: Joint Capsule Incision An incision is made in the joint capsule, allowing the surgeon to explore the interior of the glenohumeral joint.
  • Step 5: Joint Exploration The joint is thoroughly explored, and normal saline is used to flush the joint, removing any debris that may be present.
  • Step 6: Examination of Joint Structures The humeral head and glenoid fossa are examined for osteochondral defects, while the anterior and posterior labrum are evaluated for fraying or instability.
  • Step 7: Assessment of Ligaments and Tendons The anterior joint capsule, subscapularis, and glenohumeral ligaments are assessed for any signs of tears or adhesions. The biceps tendon is also examined for tears or degenerative changes.
  • Step 8: Rotator Cuff Evaluation The rotator cuff, including the supraspinatus and infraspinatus tendons, is evaluated, along with the subacromial space for any abnormalities.
  • Step 9: Posterior Joint Examination The posterior aspect of the glenohumeral joint, including the axillary pouch and posterior recess, is examined for any issues.
  • Step 10: Removal of Loose Bodies Any identified loose or foreign bodies within the joint are located and removed to alleviate symptoms and restore function.
  • Step 11: Final Flushing The joint is flushed again with normal saline to ensure all debris has been cleared before closure.
  • Step 12: Closure After completing the exploration and any necessary interventions, the incisions are closed, and a dressing is applied to protect the surgical site.

3. Post-Procedure

Following the arthrotomy of the glenohumeral joint, patients can expect specific post-procedure care and considerations. The surgical site will be monitored for signs of infection or complications. Patients may experience pain and swelling, which can be managed with prescribed medications. Rehabilitation and physical therapy may be recommended to restore range of motion and strength in the shoulder. The duration of recovery will vary based on the extent of the procedure and the individual patient's healing process. Follow-up appointments will be necessary to assess the healing progress and to determine when normal activities can be resumed.

Short Descr EXPLORE TREAT SHOULDER JOINT
Medium Descr ARTHRT GLENOHMRL JT W/JT EXPL W/WO RMVL LOOSE/FB
Long Descr Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body
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) P3D - Major procedure, orthopedic - other
MUE 1
CCS Clinical Classification 159 - Other diagnostic procedures on musculoskeletal system
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
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.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure 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)
SG Ambulatory surgical center (asc) facility service
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
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Notes
2013-01-01 Changed Medium Descriptor changed.
Pre-1990 Added Code added.
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