Overview of CPT Code 23658: Arthroscopy, shoulder, surgical

Overview of CPT Code 23658: Arthroscopy, shoulder, surgical

CPT Code 23658 refers to a surgical procedure known as arthroscopy of the shoulder. This minimally invasive technique allows orthopedic surgeons to diagnose and treat various shoulder conditions using a small camera and instruments inserted through tiny incisions.

When CPT Code 23658 is Used?

This procedure is indicated in several clinical scenarios.

• Rotator cuff tears that require surgical intervention.
• Shoulder impingement syndrome that has not responded to conservative treatment.
• Labral tears causing instability or pain.
• Shoulder arthritis leading to significant pain and dysfunction.
• Loose bodies in the shoulder joint.

Symptoms Indicating This Procedure

Patients may present with various symptoms that suggest the need for this procedure.

• Persistent shoulder pain that limits daily activities.
• Weakness in the shoulder or arm.
• Difficulty lifting the arm or reaching overhead.
• Clicking or popping sounds in the shoulder joint.
• Swelling and tenderness around the shoulder.

Causes and Risk Factors

Several factors can contribute to the conditions treated by this procedure.

• Age-related degeneration of shoulder structures.
• Repetitive overhead activities or sports.
• Previous shoulder injuries or trauma.
• Genetic predisposition to joint issues.
• Certain occupations that involve heavy lifting or overhead work.

Diagnostic Tests Before Procedure

Before undergoing arthroscopy, several diagnostic tests may be performed.

• X-rays to assess bone structure and joint space.
• MRI to visualize soft tissues, including tendons and ligaments.
• Ultrasound to evaluate shoulder movement and fluid accumulation.
• Physical examination to assess range of motion and pain.

Procedure Description

The arthroscopy procedure involves several key steps.

• The patient is placed under general or regional anesthesia.
• Small incisions are made around the shoulder joint.
• A thin camera (arthroscope) is inserted to visualize the joint.
• Surgical instruments are used to repair or remove damaged tissues.
• The incisions are closed with sutures or adhesive strips.

Preparation for the Procedure

Patients should follow specific guidelines to prepare for surgery.

• Avoid eating or drinking after midnight before the procedure.
• Discuss all medications with the surgeon, including over-the-counter drugs.
• Arrange for transportation to and from the surgical facility.
• Wear loose-fitting clothing on the day of surgery.

Recovery and Aftercare

Post-operative recovery is crucial for optimal healing.

• Rest the shoulder and avoid strenuous activities for several weeks.
• Follow prescribed physical therapy exercises to regain strength and mobility.
• Keep the surgical site clean and dry, changing dressings as instructed.
• Take pain medications as directed to manage discomfort.

Possible Complications

While generally safe, this procedure carries some risks.

• Infection at the surgical site.
• Bleeding or hematoma formation.
• Nerve or blood vessel injury.
• Stiffness or limited range of motion post-surgery.
• Failure to relieve symptoms or need for additional surgery.

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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.
• Physical therapy sessions as recommended by the surgeon.
• Ongoing assessments to evaluate pain levels and shoulder function.
• Additional imaging if complications arise.

Alternative Treatments

Non-surgical options may be considered before surgery.

• Physical therapy to strengthen shoulder muscles.
• Corticosteroid injections to reduce inflammation.
• Activity modification to avoid aggravating symptoms.
• Pain management strategies, including medications.

Home Care Tips

Patients can take steps to aid their recovery at home.

• Apply ice packs to reduce swelling and pain.
• Follow a balanced diet to support healing.
• Stay hydrated and rest adequately.
• Avoid lifting heavy objects until cleared by the doctor.

Patient Education & Prevention

Understanding prevention can help avoid future issues.

• Engage in shoulder-strengthening exercises regularly.
• Use proper techniques during sports and physical activities.
• Maintain a healthy weight to reduce joint stress.
• Seek early treatment for shoulder pain to prevent worsening.

Billing and Coding Information

CPT Code: 23658

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 a significant portion if deemed medically necessary.
• Out-of-pocket costs depend on the patient's insurance plan.

Related CPT Codes

• 23410 - Repair of Rotator Cuff
• 23412 - Arthroscopic repair of shoulder labrum
• 23420 - Arthroscopic Shoulder Surgery for Rotator Cuff Repair
• 23430 - Arthroscopy, shoulder, surgical; with rotator cuff repair
• 23600 - Closed treatment of humeral shaft fracture