CPT 23397Surgery

Muscle transfers

CPT code 23397 covers surgical muscle transfer procedures in the shoulder area, where a muscle is moved from one location to another to restore function lost due to injury, paralysis, or nerve damage.

Showing rates for

National Average

Base Medicare rate

$1,118.87

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

16.76

PE RVU (NF)

14.45

MP RVU

3.38

Total RVU

34.59

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Always append laterality modifiers (LT/RT) to prevent automatic claim rejection
Impact: Prevents 100% payment delay; claims without laterality are auto-denied and require resubmission, delaying payment 30-45 days
Document specific muscles transferred (e.g., latissimus dorsi, pectoralis major, trapezius) and their new insertion points with precise anatomical detail
Impact: Reduces medical necessity denials by 60-70%; detailed operative notes support the 16.76 work RVUs and prevent downcoding
List 23397 as the primary procedure when billing with other shoulder codes due to its high 34.59 total RVUs
Impact: Maximizes reimbursement under multiple procedure payment rules; prevents $559+ loss from incorrect sequencing with modifier 51
For complex cases with extensive scarring or revision scenarios, consider modifier 22 with comprehensive documentation and comparison to standard procedure time
Impact: Potential additional $224-$559 when approved; success rate improves to 40% with detailed dictation including time differential and complexity factors
Verify pre-authorization requirements; many commercial payers require prior approval for muscle transfer procedures as they are considered complex reconstructive surgery
Impact: Prevents 100% denial; retroactive appeals for lack of authorization have only 15-20% success rate
Ensure facility and professional components are billed correctly; facility rate equals non-facility rate ($1118.87) but billing context matters for compliance
Impact: Prevents compliance audits; incorrect place of service coding can trigger RAC audits even when payment amounts are identical

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 23397 in 2025?

The 2025 Medicare national average reimbursement for CPT 23397 is $1,118.87 for both facility and non-facility settings. This rate is based on 34.59 total RVUs multiplied by the 2025 conversion factor of 32.3465. Actual reimbursement may vary based on geographic location and local Medicare Administrative Contractor (MAC) adjustments.

How many RVUs is CPT code 23397 worth?

CPT 23397 has a total of 34.59 RVUs for 2025, consisting of 16.76 work RVUs, 14.45 practice expense RVUs (both facility and non-facility), and 3.38 malpractice RVUs. The high work RVU reflects the complexity and time required for muscle transfer procedures.

What modifiers are commonly used with CPT 23397?

The most commonly used modifiers with CPT 23397 include LT/RT (laterality), modifier 50 (bilateral procedures), modifier 22 (increased procedural services for complex cases), modifier 51 (multiple procedures), and modifier 58 (staged procedures during global period). Laterality modifiers are mandatory for claim processing.

What is the difference between CPT 23397 and rotator cuff repair codes?

CPT 23397 involves transferring an entire muscle from one location to another to restore lost function, typically for irreparable conditions. Rotator cuff repair codes (23410-23420) involve repairing torn tendons of existing rotator cuff muscles. Muscle transfers are generally more complex, reserved for cases where primary repair is not feasible, and carry higher RVU values.

Does CPT 23397 require prior authorization from insurance?

Most commercial payers and Medicare Advantage plans require prior authorization for CPT 23397 due to its classification as complex reconstructive surgery. Traditional Medicare typically does not require pre-authorization, but medical necessity must still be documented. Always verify authorization requirements with the specific payer before scheduling.

Can CPT 23397 be billed bilaterally?

Yes, CPT 23397 can be billed bilaterally using modifier 50 when muscle transfers are performed on both shoulders during the same operative session. Bilateral billing typically reimburses at 150% of the single procedure rate, but each shoulder must have independent medical necessity documentation and bilateral performance must be clearly documented in the operative report.

What documentation is required to support medical necessity for CPT 23397?

Required documentation includes diagnostic imaging confirming irreparable muscle or tendon damage, evidence of failed conservative treatment (typically 6+ months of physical therapy), functional deficit measurements (ROM, strength testing, ADL limitations), operative report detailing specific muscles transferred and technique used, and clinical notes explaining why muscle transfer is medically necessary versus alternative treatments.