CPT 23462Surgery

Repair shoulder capsule

CPT code 23462 covers surgical repair of the shoulder capsule, the fibrous tissue envelope that surrounds and stabilizes the shoulder joint. This procedure is typically performed to treat shoulder instability, recurrent dislocations, or capsular tears.

Showing rates for

National Average

Base Medicare rate

$1,050.61

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

15.72

PE RVU (NF)

13.56

MP RVU

3.2

Total RVU

32.48

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

NCCI bundling edits

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Billing tips

Verify the procedure is not part of a more comprehensive capsulorrhaphy or instability repair (23465, 23466) which bundle capsular repair work
Impact: Prevents downcoding from $1050.61 to denial or bundling; comprehensive procedures have different RVU values
Document specific capsular tear location, size in centimeters, repair technique (suture type, number of anchors), and why open approach was medically necessary over arthroscopic
Impact: Supports medical necessity and prevents denials requesting additional documentation; reduces audit risk by 60-70%
Bill facility rate ($1050.61) when performed in ASC or hospital; non-facility rate applies only in office setting which is inappropriate for this procedure
Impact: Both rates identical at $1050.61 for 2025, but correct place of service code (POS 22 or 24) required for processing
Include diagnosis codes documenting capsular pathology (M24.811-M24.819 for shoulder joint disorder, S43.401A-S43.499A for capsular sprain/tear)
Impact: Links medical necessity; vague codes like M25.519 (shoulder pain) increase denial risk by 40%
When performed with rotator cuff repair, ensure capsular work is separately documented and not integral to cuff repair methodology
Impact: May support modifier 59 use but high audit risk; most payers consider capsular work incidental to rotator cuff procedures
Submit operative report with initial claim when billing with modifier 22 or when combined with other shoulder procedures
Impact: Reduces processing delays by 15-20 days; supports higher reimbursement and prevents automatic denials for bundling

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23462 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 23462 is $1050.61 for both facility and non-facility settings. This is based on 32.48 total RVUs multiplied by the 2025 conversion factor of 32.3465. Actual payment varies by geographic locality.

Can CPT 23462 be billed with arthroscopic shoulder procedures?

Billing 23462 (open capsular repair) with arthroscopic procedures requires careful documentation. Most payers consider the capsular work bundled unless performed through a separate incision on distinct anatomy with modifier 59. This combination faces high audit scrutiny and often requires peer-to-peer review.

What diagnosis codes support medical necessity for 23462?

Primary diagnosis codes include M24.81- (shoulder joint disorder), S43.40-S43.49 (capsular sprain/tear of shoulder), M75.1- (rotator cuff tear with capsular involvement), and M24.01- (loose body in shoulder joint). The diagnosis must demonstrate structural capsular pathology requiring surgical repair.

Is modifier 22 commonly approved for CPT 23462?

Modifier 22 approval for 23462 is case-specific and requires extensive documentation showing significantly increased work. Acceptable scenarios include revision surgery with scar tissue, extensive capsular deficiency requiring graft augmentation, or complex anatomy. Approval rate is approximately 30-40% without peer review, potentially increasing payment 20-40%.

How does 23462 differ from capsulorrhaphy codes 23465 and 23466?

CPT 23462 is for capsular repair without addressing instability, while 23465 and 23466 are comprehensive anterior capsulorrhaphy procedures for glenohumeral instability with specific Putti-Platt or Bankart approaches. The 23465/23466 codes bundle capsular repair work and have higher RVU values (35.29 and 37.08 respectively).

What are the work RVUs for CPT 23462 in 2025?

CPT 23462 has 15.72 work RVUs, 13.56 practice expense RVUs (both facility and non-facility), and 3.2 malpractice RVUs, totaling 32.48 RVUs. This reflects a major surgical procedure requiring significant physician time, skill, and postoperative care.

Do I need prior authorization for CPT 23462?

Prior authorization requirements vary by payer. Most Medicare Advantage plans and commercial insurers require preauthorization for 23462 as an outpatient surgical procedure. Traditional Medicare does not require prior authorization but may conduct post-payment review. Check specific payer policies 5-7 business days before scheduling.