CPT 23455Surgery

Repair shoulder capsule

CPT code 23455 covers surgical repair of the shoulder capsule, the fibrous tissue that surrounds and stabilizes the shoulder joint. This procedure is performed to restore shoulder stability after injuries like dislocations or capsular tears.

Showing rates for

National Average

Base Medicare rate

$956.81

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

14.67

PE RVU (NF)

12.16

MP RVU

2.75

Total RVU

29.58

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

NCCI bundling edits

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Billing tips

Always append laterality modifier (LT/RT) on first submission to avoid automatic rejection
Impact: Prevents claim rejection and 2-3 week payment delay; required for all shoulder procedures
Document medical necessity for open approach vs arthroscopic repair in operative report
Impact: Prevents downcoding to arthroscopic capsulorrhaphy (29806); open approach typically has higher complexity justification
Verify global period (90 days) and coordinate with physical therapy billing to avoid denials for post-op care included in surgical package
Impact: Prevents inappropriate billing of $200-400 in E/M services during global period
For revision capsule repairs, use modifier 22 with detailed comparison of additional work versus primary repair
Impact: Can increase reimbursement by $191-287 (20-30% above base rate of $956.81) with proper documentation
Separately report significant bone procedures (e.g., glenoid bone grafting) if performed, with modifier 59/XS when appropriate
Impact: May add $500-1500 additional reimbursement if procedures are truly distinct and documented separately
Submit with ICD-10 codes specifying traumatic vs atraumatic instability and laterality (S43.006A for initial traumatic dislocation vs M24.311 for recurrent dislocation)
Impact: Accurate diagnosis coding supports medical necessity and reduces audit risk; mismatch between diagnosis and procedure triggers review

Applicable modifiers

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23455 in 2025?

The 2025 Medicare national average payment for CPT 23455 is $956.81 for both facility and non-facility settings. This rate is based on 29.58 total RVUs (14.67 work RVU, 12.16 practice expense RVU, and 2.75 malpractice RVU) multiplied by the 2025 conversion factor of 32.3465.

What is the difference between CPT 23455 and arthroscopic shoulder capsulorrhaphy?

CPT 23455 is an open surgical repair of the shoulder capsule requiring a larger incision and direct visualization, while arthroscopic capsulorrhaphy (CPT 29806) is performed through small incisions using a camera and specialized instruments. The open approach (23455) is typically reserved for more extensive capsular damage, revision cases, or when arthroscopic repair is not feasible.

Can CPT 23455 be billed with a rotator cuff repair on the same day?

Yes, but with caution. If a rotator cuff repair is performed as a distinct, separately identifiable procedure during the same operative session, it may be separately billable with appropriate modifier (59, XS, or XU). However, documentation must clearly demonstrate that both procedures were medically necessary and not components of a single surgical objective. Review NCCI edits to ensure procedures are not bundled.

What modifiers are required when billing CPT 23455?

Laterality modifiers LT (left) or RT (right) are mandatory for CPT 23455. Additional modifiers may include 22 for increased complexity, 50 for bilateral procedures (rare), 59/XS for distinct procedural services, 78 for return to OR during global period, or 79 for unrelated procedures during postoperative period.

How many RVUs is CPT code 23455 worth?

CPT 23455 has a total of 29.58 RVUs in 2025, consisting of 14.67 work RVUs, 12.16 practice expense RVUs (both facility and non-facility), and 2.75 malpractice RVUs. This high RVU value reflects the complexity and intensity of open shoulder capsule repair surgery.

What diagnosis codes support medical necessity for CPT 23455?

Common supporting ICD-10 codes include S43.006A (unspecified dislocation of right shoulder, initial encounter), M24.311/M24.312 (recurrent dislocation of shoulder), S43.431A/S43.432A (superior glenoid labrum lesion), and M25.311/M25.312 (instability of shoulder joint). Documentation must demonstrate structural pathology requiring surgical capsular repair.

What is the global period for CPT 23455?

CPT 23455 has a 90-day global surgical period. This means all routine postoperative care, including follow-up visits, wound care, and uncomplicated post-operative management within 90 days of surgery, is included in the surgical fee and cannot be billed separately. Only complications or unrelated conditions may be billed during this period with appropriate modifiers.