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Official Description

Osteotomy, clavicle, with or without internal fixation;

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

An osteotomy of the clavicle, as described by CPT® Code 23480, is a surgical procedure aimed at correcting various conditions affecting the clavicle, which is the bone connecting the arm to the body. This procedure is particularly indicated for issues such as chronic dislocation of the sternoclavicular joint, as well as malunion or nonunion of the clavicle. The term 'osteotomy' refers to the surgical cutting of bone, and in this case, it is performed without the use of bone grafting. The specific location of the osteotomy is determined based on the underlying condition being treated. The procedure involves making a skin incision over the designated site on the clavicle, followed by the exposure of the bone. Drill holes are created at both the lateral and medial sides of the planned osteotomy site, allowing for precise cuts to be made. A horizontal cut is executed between these drill holes, and additional vertical cuts are made to form a Z-osteotomy, which facilitates the lengthening of the clavicle by sliding the cut edges apart. The stabilization of the bone is achieved through the use of sutures or internal fixation devices, ensuring proper alignment and support during the healing process.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The osteotomy of the clavicle, coded as CPT® 23480, is indicated for the following conditions:

  • Chronic dislocation of the sternoclavicular joint - This condition involves the persistent displacement of the joint where the clavicle meets the sternum, leading to pain and dysfunction.
  • Malunion of the clavicle - This refers to a situation where a previously fractured clavicle has healed improperly, resulting in misalignment and potential complications.
  • Nonunion of the clavicle - This condition occurs when a fractured clavicle fails to heal completely, leaving the bone ends separated and causing ongoing pain and instability.

2. Procedure

The procedure for CPT® Code 23480 involves several critical steps to ensure successful osteotomy of the clavicle:

  • Step 1: Skin incision - A skin incision is made over the planned osteotomy site on the clavicle, allowing access to the bone for the surgical procedure.
  • Step 2: Bone exposure - The clavicle is carefully exposed to provide a clear view of the area where the osteotomy will be performed, ensuring that surrounding tissues are preserved as much as possible.
  • Step 3: Drill holes - Drill holes are created at the lateral and medial aspects of the planned osteotomy site. These holes serve as guides for the subsequent bone cuts.
  • Step 4: Horizontal bone cut - A horizontal cut is made between the two drill holes, which is essential for the osteotomy process.
  • Step 5: Vertical cuts - Vertical cuts are made at the inferomedial and superolateral aspects of the horizontal cut, forming a Z-osteotomy configuration that allows for the lengthening of the clavicle.
  • Step 6: Lengthening the clavicle - The cut edges of the clavicle are then slid apart to achieve the desired lengthening, addressing the underlying condition.
  • Step 7: Stabilization - Holes are drilled on each side of the lateral cuts, and sutures are threaded through these holes to secure the bones in place. Alternatively, internal fixation devices such as screws or plates may be used to stabilize the osteotomy site.

3. Post-Procedure

After the osteotomy procedure is completed, appropriate post-operative care is essential for recovery. The surgical wound is typically closed in layers to promote healing and minimize the risk of infection. A dressing is applied to protect the incision site. Patients may be advised on specific rehabilitation protocols to restore function and strength to the shoulder and arm. Follow-up appointments are crucial to monitor the healing process and ensure that the clavicle is properly aligned and stable during recovery.

Short Descr REVISION OF COLLAR BONE
Medium Descr OSTEOTOMY CLAVICLE W/WO INTERNAL FIXATION
Long Descr Osteotomy, clavicle, with or without internal fixation;
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 161 - Other OR therapeutic procedures on bone
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.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
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.)
AG Primary physician
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)
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
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
Date
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2010-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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