CPT 23465Surgery

Repair shoulder capsule

CPT 23465 covers surgical repair of the shoulder capsule, the fibrous tissue that surrounds the shoulder joint and keeps it stable. This procedure is performed when the capsule is torn or damaged, typically due to dislocation or instability.

Showing rates for

National Average

Base Medicare rate

$1,100.75

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

16.3

PE RVU (NF)

14.41

MP RVU

3.32

Total RVU

34.03

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

NCCI bundling edits

Loading bundling edits…

Billing tips

Document whether repair is primary or revision surgery; revision cases may justify modifier 22 for increased complexity
Impact: Modifier 22 can increase reimbursement by $220-550 when supported by extensive documentation of additional work
Clearly distinguish open capsule repair (23465) from arthroscopic capsulorrhaphy (29806) in operative report; approach determines code selection
Impact: Code confusion causes denial; 29806 pays differently and requires different documentation
Link appropriate diagnosis codes for instability (M24.411/M24.412) or dislocation history (M24.311/M24.312) to support medical necessity
Impact: Missing or inappropriate diagnosis codes account for 30-40% of denials; proper linkage prevents medical necessity denials
Bill facility and non-facility codes correctly based on place of service; this code shows equal facility and non-facility rates
Impact: Both settings reimburse at $1100.75, but PE RVU allocation remains identical at 14.41, simplifying billing verification
Do not unbundle capsule repair from comprehensive shoulder stabilization procedures; review NCCI edits before billing multiple codes
Impact: Unbundling violations result in 100% denial of bundled code and potential fraud investigation
Verify global period (90 days) and avoid billing separately for routine postoperative care during this window
Impact: Billing E/M services during global period without appropriate modifier causes automatic denial and potential audit

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Frequently asked questions

What is the 2025 Medicare reimbursement rate for CPT 23465?

The 2025 Medicare national average reimbursement for CPT 23465 is $1100.75 for both facility and non-facility settings. The code carries 34.03 total RVUs (16.3 work RVU, 14.41 PE RVU, 3.32 MP RVU) with the 2025 conversion factor of 32.3465.

What is the difference between CPT 23465 and 29806?

CPT 23465 describes open surgical repair of the shoulder capsule through a traditional incision, while 29806 describes arthroscopic capsulorrhaphy performed through small portals with camera guidance. The approach (open versus arthroscopic) determines which code to use, and the operative report must clearly document the surgical technique.

What modifiers are required when billing CPT 23465?

Laterality modifiers LT (left) or RT (right) are required for CPT 23465. Additional modifiers may include 50 for bilateral procedures, 22 for increased complexity, 51 for multiple procedures, 78 for related return to OR, or 79 for unrelated procedures during the global period.

How many RVUs is CPT code 23465 worth in 2025?

CPT 23465 has 34.03 total RVUs in 2025, consisting of 16.3 work RVUs, 14.41 practice expense RVUs (both facility and non-facility), and 3.32 malpractice RVUs. This is considered a high-value surgical procedure.

What diagnosis codes support medical necessity for CPT 23465?

Common supporting diagnosis codes include M24.411/M24.412 (recurrent dislocation of shoulder), M24.311/M24.312 (pathological dislocation of shoulder), S43.006A/S43.005A (unspecified dislocation), and M25.311/M25.312 (instability of joint, shoulder). Documentation must show failed conservative treatment.

Can CPT 23465 be billed with other shoulder stabilization codes?

CPT 23465 may be subject to NCCI bundling edits with other shoulder stabilization procedures. Review current NCCI edits before billing multiple codes together. When procedures are distinct and separate, modifier 59 or XU may be appropriate with detailed documentation explaining the separate nature of the services.

What is the global period for CPT 23465?

CPT 23465 has a 90-day global period. All routine postoperative care within 90 days of surgery is included in the reimbursement. E/M services during this period require modifier 24 (unrelated) or 25 (significant, separately identifiable service on same day) with documentation supporting the separate nature of the service.