CPT 23460Surgery

Repair shoulder capsule

CPT code 23460 covers surgical repair of the shoulder capsule, the fibrous tissue that surrounds and stabilizes the shoulder joint. This procedure is typically performed to treat shoulder instability or dislocation.

Showing rates for

National Average

Base Medicare rate

$1,073.90

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

15.82

PE RVU (NF)

14.15

MP RVU

3.23

Total RVU

33.2

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

NCCI bundling edits

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Billing tips

Always append laterality modifier (LT or RT) on first submission to avoid automatic denials and claim reprocessing delays
Impact: Prevents initial denial and 2-4 week payment delay
Document the specific type of capsular pathology (Bankart lesion, capsular redundancy, ALPSA lesion) and technique (shift procedure, capsular plication, bone anchor repair) to support medical necessity
Impact: Reduces medical necessity denials by approximately 40% and supports modifier 22 when applicable
Verify authorization requirements before surgery; many payers require pre-authorization for open shoulder stabilization with specific imaging documentation
Impact: Prevents entire claim denial ($1073.90 at risk); authorization denials are difficult to overturn retroactively
When billing with rotator cuff repair codes (29827, 23412), ensure documentation clearly separates capsular repair from cuff work to justify both procedures
Impact: Prevents bundling or downcoding that could reduce payment by 50% ($536.95 loss)
For revision capsulorrhaphy, use modifier 22 with detailed comparison to initial procedure complexity, operative time, and additional techniques required
Impact: Can increase reimbursement by $214-$322 when properly documented with operative report and cover letter
Bill facility vs non-facility setting accurately; verify place of service code matches actual location to ensure proper rate application
Impact: Both rates are identical at $1073.90 for 23460, but incorrect POS coding triggers audit flags

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23460 in 2025?

The 2025 Medicare national average reimbursement for CPT 23460 is $1073.90 for both facility and non-facility settings, based on 33.2 total RVUs and a conversion factor of 32.3465.

What is the difference between CPT 23460 and 29806?

CPT 23460 describes open capsulorrhaphy requiring a surgical incision with direct visualization, while 29806 describes arthroscopic capsulorrhaphy performed through small portals with a camera. The approach must be clearly documented to support code selection.

Can CPT 23460 be billed with rotator cuff repair codes?

Yes, but documentation must clearly show distinct pathology and separate work on the capsule versus rotator cuff tendons. Modifier 59 may be required, and detailed operative notes describing both procedures independently are essential to prevent bundling denials.

What modifiers are required when billing CPT 23460?

Laterality modifiers LT (left) or RT (right) are mandatory for every claim. Additional modifiers like 51 (multiple procedures), 22 (increased complexity), or 50 (bilateral) may apply based on specific clinical circumstances.

How many RVUs is CPT code 23460 worth?

CPT 23460 has 33.2 total RVUs for 2025, consisting of 15.82 work RVUs, 14.15 practice expense RVUs, and 3.23 malpractice RVUs.

Does CPT 23460 require pre-authorization from insurance?

Most commercial payers and Medicare Advantage plans require pre-authorization for CPT 23460 as it is an elective surgical procedure. Requirements vary by payer, but typically include documentation of failed conservative treatment and diagnostic imaging confirming capsular pathology.

What documentation is needed to support medical necessity for CPT 23460?

Required documentation includes history of recurrent shoulder instability or dislocation, physical examination findings of instability (apprehension test, anterior drawer), diagnostic imaging (MRI or CT arthrogram) showing capsular pathology, and records of failed conservative treatment including physical therapy for 6-12 weeks.