CPT code 23465 is a medical code used to describe the procedure for repairing the shoulder capsule.
CPT code 23465 is used to describe a surgical procedure for repairing the shoulder capsule. This procedure typically involves tightening or reconstructing the capsule, which is the fibrous tissue surrounding the shoulder joint, to improve stability and function. This code is often used when addressing issues such as shoulder dislocations or instability that have not responded to non-surgical treatments.
When billing for CPT code 23465 (Repair shoulder capsule), it is essential to consider the appropriate use of modifiers to ensure accurate reimbursement and compliance with payer requirements. Below is a list of modifiers that could be used with CPT code 23465, along with the reasons for their use:
1. Modifier -50 (Bilateral Procedure): Used when the repair of the shoulder capsule is performed on both shoulders during the same surgical session.
2. Modifier -51 (Multiple Procedures): Applied when multiple procedures are performed during the same surgical session. This modifier indicates that the repair of the shoulder capsule is one of several procedures.
3. Modifier -59 (Distinct Procedural Service): Used to indicate that the repair of the shoulder capsule is a distinct procedural service from other services performed on the same day. This modifier is essential when procedures are not typically reported together but are appropriate under the circumstances.
4. Modifier -RT (Right Side): Indicates that the repair of the shoulder capsule was performed on the right shoulder.
5. Modifier -LT (Left Side): Indicates that the repair of the shoulder capsule was performed on the left shoulder.
6. Modifier -22 (Increased Procedural Services): Used when the work required to perform the repair of the shoulder capsule is substantially greater than typically required. Documentation must support the increased complexity.
7. Modifier -78 (Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period): Applied if the patient requires an unplanned return to the operating room for a related procedure during the postoperative period of the initial shoulder capsule repair.
8. Modifier -79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): Used when an unrelated procedure is performed by the same physician during the postoperative period of the initial shoulder capsule repair.
9. Modifier -80 (Assistant Surgeon): Indicates that an assistant surgeon was required to perform the shoulder capsule repair.
10. Modifier -81 (Minimum Assistant Surgeon): Used when a minimum assistant surgeon was required for the procedure.
11. Modifier -82 (Assistant Surgeon (when qualified resident surgeon not available)): Applied when an assistant surgeon is necessary because a qualified resident surgeon is not available.
12. Modifier -AS (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery): Indicates that a non-physician provider assisted in the surgery.
Proper use of these modifiers ensures that the claim accurately reflects the services provided and supports appropriate reimbursement. Always refer to the latest coding guidelines and payer-specific requirements when applying modifiers.
The reimbursement of CPT code 23465 by Medicare depends on its inclusion in the Medicare Physician Fee Schedule (MPFS) and the specific guidelines set forth by the Medicare Administrative Contractor (MAC) for your region. To determine if CPT code 23465 is reimbursed by Medicare, you should first consult the MPFS, which lists the payment rates for services covered by Medicare. Additionally, each MAC may have unique coverage policies and local coverage determinations (LCDs) that could affect reimbursement. Therefore, it is essential to verify with your regional MAC to ensure that CPT code 23465 is eligible for reimbursement under Medicare guidelines.
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