Overview of CPT Code 21495:Removal of implant, shoulder
CPT Code 21495 refers to the surgical procedure for the removal of an implant from the shoulder joint. This procedure is typically performed when an implant, such as a plate or screw, is no longer needed or is causing complications.
When CPT Code 21495 is Used?
This procedure is indicated in several clinical scenarios.
- Removal of a shoulder implant due to infection.
- Removal of an implant after fracture healing.
- Complications arising from the implant, such as pain or discomfort.
- Revision surgery for failed shoulder arthroplasty.
Symptoms Indicating This Procedure
Patients may report various symptoms that lead to the consideration of this procedure.
- Persistent pain in the shoulder joint.
- Swelling or inflammation around the implant site.
- Limited range of motion in the shoulder.
- Signs of infection, such as fever or drainage.
Causes and Risk Factors
Several factors can contribute to the need for implant removal.
- Infection at the implant site.
- Mechanical failure of the implant.
- Allergic reactions to implant materials.
- Previous shoulder surgeries or trauma.
Diagnostic Tests Before Procedure
Before the procedure, certain diagnostic tests may be performed.
- X-rays to assess the position and condition of the implant.
- MRI to evaluate soft tissue and detect infection.
- Blood tests to check for signs of infection or inflammation.
Procedure Description
The procedure involves several key steps.
- Administer anesthesia to ensure patient comfort.
- Make an incision over the shoulder to access the implant.
- Carefully remove the implant using surgical instruments.
- Inspect the surrounding tissue for any signs of damage or infection.
- Close the incision with sutures or staples.
Preparation for the Procedure
Patients should follow specific guidelines before the surgery.
- Avoid eating or drinking for at least 8 hours before the procedure.
- Discuss any medications with the healthcare provider.
- Arrange for transportation home after the procedure.
- Wear loose-fitting clothing on the day of surgery.
Recovery and Aftercare
Post-operative care is crucial for recovery.
- Rest the shoulder and avoid heavy lifting for several weeks.
- Keep the incision site clean and dry.
- Follow up with the healthcare provider for suture removal.
- Take prescribed pain medications as needed.
Possible Complications
As with any surgical procedure, there are potential risks.
- Infection at the surgical site.
- Nerve or blood vessel damage.
- Persistent pain or discomfort.
- Delayed healing or complications from anesthesia.
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Post-Procedure Follow-Up
Regular follow-up is essential for monitoring recovery.
- Initial follow-up appointment within 1-2 weeks post-surgery.
- Additional visits as needed to assess healing.
- Physical therapy may be recommended to restore function.
Alternative Treatments
Non-surgical options may be considered before surgery.
- Physical therapy to strengthen shoulder muscles.
- Medications for pain management.
- Corticosteroid injections to reduce inflammation.
Home Care Tips
Patients can take steps to aid their recovery at home.
- Apply ice packs to reduce swelling.
- Keep the arm elevated to minimize discomfort.
- Engage in gentle range-of-motion exercises as advised.
Patient Education & Prevention
Understanding risks can help prevent complications.
- Recognize signs of infection and seek prompt care.
- Follow post-operative instructions carefully.
- Maintain a healthy lifestyle to support healing.
Billing and Coding Information
CPT Code: 21495
Category: Surgical Procedures
Common Modifiers:
- 50 - Bilateral procedure
- RT - Right side
- LT - Left side
Average Cost and Insurance Coverage
Costs can vary based on several factors.
- Average cost ranges from $3,000 to $10,000.
- Insurance may cover the procedure if deemed medically necessary.
- Out-of-pocket costs depend on the insurance plan.
Related CPT Codes
References and Sources
Frequently Asked Questions (FAQs)
What is the purpose of removing a shoulder implant?
The implant may be removed due to complications, infection, or after the healing process.
How long does the procedure take?
The procedure typically takes about 1 to 2 hours.
Will I need physical therapy after surgery?
Yes, physical therapy is often recommended to restore strength and mobility.
What are the signs of infection I should watch for?
Look for increased redness, swelling, warmth, or discharge at the incision site.
