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The procedure described by CPT® Code 23415 involves the release of the coracoacromial ligament, which is a critical structure in the shoulder joint. This ligament connects the coracoid process, located on the anterior aspect of the scapula, to the acromion process on the posterior scapula, playing a vital role in stabilizing the shoulder joint. The procedure typically begins with a skin incision made on the superior aspect of the shoulder, directly over the coracoacromial ligament. Following the incision, the surgeon dissects through the soft tissues to expose the ligament. Once exposed, the shoulder joint is thoroughly explored to confirm any impingement of the rotator cuff against the edge of the acromion, which is often associated with the attachment of the coracoacromial ligament. If impingement is confirmed, the ligament is released by detaching it from the undersurface of the acromion. Additionally, the ligament may be debrided using a shaver to remove any degenerated tissue. The undersurface of the acromion is then inspected to assess whether an acromioplasty is necessary. If acromioplasty is indicated, the surgeon will smooth the undersurface of the acromion using an end-cutting motorized shaver. A burr may also be utilized to eliminate any remaining ligament fibers and to clearly define the anterolateral surface of the acromion. Finally, the surgical site is irrigated with sterile saline, and the incisions are meticulously closed in layers to promote optimal healing.
© Copyright 2025 Coding Ahead. All rights reserved.
The coracoacromial ligament release procedure is indicated for patients experiencing shoulder pain and dysfunction due to impingement of the rotator cuff. This condition may arise from various factors, including anatomical variations, degenerative changes, or trauma that leads to the compression of the rotator cuff against the acromion. The following specific indications may warrant this surgical intervention:
The procedure for coracoacromial ligament release involves several critical steps to ensure effective treatment of shoulder impingement. The following procedural steps are performed:
After the coracoacromial ligament release procedure, patients can expect a recovery period that may involve pain management and rehabilitation. Post-operative care typically includes the following considerations:
| Short Descr | RELEASE OF SHOULDER LIGAMENT | Medium Descr | CORACOACROMIAL LIGAMENT RELEAS W/WOACROMIOPLASTY | Long Descr | Coracoacromial ligament release, with or without acromioplasty | 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 | 150 - Division of joint capsule, ligament or cartilage |
| 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. | 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) | 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. | 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). | 81 | Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number. | 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 | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | 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 |
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| Pre-1990 | Added | Code added. |
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