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An anterior capsulorrhaphy is a surgical procedure aimed at repairing the shoulder capsule to address instability of the glenohumeral joint, which is the ball-and-socket joint of the shoulder. This instability often results from recurrent anterior dislocations of the shoulder, where the head of the humerus dislocates forward out of the socket. The procedure can be performed using different techniques, categorized into anatomic and nonanatomic repairs. Anatomic repairs focus on directly repairing the damaged or disrupted structures of the shoulder, restoring them to their original state. In contrast, nonanatomic repairs involve shortening or tightening the shoulder structures to enhance joint stability and prevent future dislocations. The specific procedure described by CPT® Code 23460 involves the use of a bone block, also known as a bone graft, to reinforce the repair. The surgical approach begins with an incision over the anterior shoulder, allowing access to the joint capsule. The surgeon dissects through the soft tissues to expose and open the joint capsule, where the injury is addressed. Depending on the nature of the injury, the subscapularis muscle may be shortened or tightened, or the joint structures may be repaired directly. A bone graft is then prepared, which can be an autograft (harvested from the patient) or an allograft (obtained from a bone bank). This graft is shaped and placed into the defect to provide additional support. After the repair, the soft tissues are closed over the joint, and the skin is sutured in layers to complete the procedure.
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The procedure described by CPT® Code 23460 is indicated for the following conditions:
The surgical procedure for CPT® Code 23460 involves several key steps to effectively repair the shoulder capsule:
Post-procedure care following an anterior capsulorrhaphy with bone block involves monitoring the patient for any complications and ensuring proper healing. Patients are typically advised to follow a rehabilitation program that includes physical therapy to restore range of motion and strength in the shoulder. The recovery period may vary depending on the extent of the surgery and the individual patient's healing process. It is important for patients to adhere to follow-up appointments to assess the success of the procedure and to make any necessary adjustments to their rehabilitation plan.
| Short Descr | REPAIR SHOULDER CAPSULE | Medium Descr | CAPSULORRHAPHY ANTERIOR WITH BONE BLOCK | Long Descr | Capsulorrhaphy, anterior, any type; with bone block | 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 | Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate. | 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 |
| 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. | 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). | 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) |
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| Pre-1990 | Added | Code added. |
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