Overview of CPT Code 23625: Arthroscopy, shoulder, diagnostic
CPT Code 23625 refers to a diagnostic arthroscopy of the shoulder, a minimally invasive surgical procedure used to visualize, diagnose, and treat issues within the shoulder joint.
When CPT Code 23625 is Used?
This procedure is indicated in various clinical scenarios.
- Persistent shoulder pain not responding to conservative treatment.
- Suspected rotator cuff tears.
- Shoulder instability or dislocation.
- Assessment of joint damage due to arthritis.
- Evaluation of loose bodies or other intra-articular abnormalities.
Symptoms Indicating This Procedure
Patients may report several symptoms that lead to the consideration of this procedure.
- Chronic shoulder pain or discomfort.
- Limited range of motion in the shoulder.
- Swelling or tenderness around the shoulder joint.
- Popping or clicking sounds during shoulder movement.
- Weakness in the shoulder or arm.
Causes and Risk Factors
Several factors can contribute to shoulder issues requiring diagnostic arthroscopy.
- Age-related degeneration of shoulder structures.
- Previous shoulder injuries or trauma.
- Repetitive overhead activities or sports.
- Genetic predisposition to joint problems.
- Underlying conditions such as rheumatoid arthritis.
Diagnostic Tests Before Procedure
Prior to the procedure, several diagnostic tests may be performed.
- X-rays to assess bone structure and joint alignment.
- MRI to visualize soft tissues, including ligaments and tendons.
- Ultrasound for real-time imaging of shoulder structures.
- Physical examination to evaluate range of motion and pain.
Procedure Description
The diagnostic arthroscopy procedure involves several key steps.
- Patient is positioned comfortably, usually in a sitting or lying position.
- Anesthesia is administered, either general or regional.
- Small incisions are made around the shoulder joint.
- A thin, flexible tube with a camera (arthroscope) is inserted into the joint.
- The surgeon examines the joint for abnormalities and may take biopsies or perform minor repairs.
- The arthroscope is removed, and incisions are closed with sutures.
Preparation for the Procedure
Patients should follow specific guidelines to prepare for the procedure.
- Avoid eating or drinking for at least 8 hours before the procedure.
- Discuss current medications with the healthcare provider.
- Arrange for transportation home after the procedure.
- Wear loose-fitting clothing for comfort post-surgery.
- Follow any specific instructions provided by the healthcare team.
Recovery and Aftercare
Post-procedure recovery involves several important aspects.
- Rest the shoulder and avoid strenuous activities for several weeks.
- Follow-up appointments to monitor healing and assess results.
- Ice the shoulder to reduce swelling and pain.
- Take prescribed pain medications as needed.
- Gradual physical therapy may be recommended to restore function.
Possible Complications
While generally safe, there are potential risks associated with this procedure.
- Infection at the incision site.
- Bleeding or hematoma formation.
- Nerve or blood vessel injury.
- Persistent pain or stiffness in the shoulder.
- Failure to resolve the underlying issue.
Secure, compliant, and built for trust
HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.
Learn more
Post-Procedure Follow-Up
Monitoring after the procedure is crucial for recovery.
- Initial follow-up within 1-2 weeks to check incision healing.
- Further assessments at 4-6 weeks to evaluate shoulder function.
- Long-term follow-up may be necessary based on findings and treatment.
Alternative Treatments
Before considering surgery, several non-surgical options may be explored.
- Physical therapy to strengthen shoulder muscles.
- Corticosteroid injections to reduce inflammation.
- Activity modification to avoid aggravating symptoms.
- Over-the-counter pain medications for symptom relief.
- Heat or ice therapy to manage pain.
Home Care Tips
Patients can take several steps at home to aid recovery.
- Keep the surgical area clean and dry.
- Follow prescribed exercises to improve mobility.
- Use ice packs to manage swelling.
- Avoid lifting heavy objects until cleared by a doctor.
- Stay hydrated and maintain a balanced diet for healing.
Patient Education & Prevention
Understanding shoulder health can help prevent future issues.
- Engage in regular shoulder-strengthening exercises.
- Practice proper techniques during sports and physical activities.
- Avoid repetitive overhead motions when possible.
- Maintain a healthy weight to reduce joint stress.
- Seek early evaluation for persistent shoulder pain.
Billing and Coding Information
CPT Code: 23625
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 $5,000 to $15,000.
- Insurance may cover the procedure if deemed medically necessary.
- Out-of-pocket costs depend on the insurance plan and deductible.
Related CPT Codes
Frequently Asked Questions (FAQs)
What is the purpose of a shoulder arthroscopy?
It allows doctors to diagnose and treat shoulder problems with minimal incisions.
How long does the procedure take?
The procedure typically takes about 30 minutes to an hour.
Will I need physical therapy after surgery?
Yes, physical therapy is often recommended to aid recovery.
What can I expect during recovery?
You may experience some pain and swelling, which can be managed with ice and medication.
Are there any risks associated with the procedure?
As with any surgery, there are risks such as infection and bleeding.
