CPT 23466Surgery

Repair shoulder capsule

CPT code 23466 covers surgical repair of the shoulder capsule, the fibrous tissue envelope that surrounds and stabilizes the shoulder joint. This procedure is typically performed to restore shoulder stability after dislocation or chronic instability conditions.

Showing rates for

National Average

Base Medicare rate

$1,103.34

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

15.8

PE RVU (NF)

15.17

MP RVU

3.14

Total RVU

34.11

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 as this is a bilateral procedure code; claims will auto-deny without it
Impact: Prevents 100% claim denial and resubmission delays of 30-45 days
Document exact capsular repair technique (shift, plication, advancement) and distinguish from arthroscopic approach (29806) to support open procedure code selection
Impact: Prevents downcoding to arthroscopic rate which reimburses $500-600 less
When performing with rotator cuff repair, verify code combination is not subject to CCI bundling; may require modifier 59 with detailed documentation of separate pathology
Impact: Protects $1103.34 reimbursement from bundling into rotator cuff code only
For revision capsulorrhaphy cases, append modifier 22 with operative note documenting increased work from adhesions, bone loss, or failed hardware removal
Impact: Can increase reimbursement by $220-$551 (20-50% above base rate)
Bill facility and non-facility rates accurately; both are $1103.34 for 23466, so setting documentation must match claim type to avoid audit flags
Impact: Prevents recoupment requests during post-payment audits
Code to highest specificity; if Bankart lesion repair is primary pathology, consider 23455 instead which may have different coverage policies
Impact: Ensures optimal reimbursement and reduces medical necessity denials

Common denials

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23466 in 2025?

The 2025 Medicare national average reimbursement for CPT 23466 is $1103.34 for both facility and non-facility settings, based on the CMS Physician Fee Schedule with a conversion factor of 32.3465.

How many RVUs is CPT code 23466 worth?

CPT 23466 has a total RVU value of 34.11, consisting of 15.8 work RVUs, 15.17 practice expense RVUs, and 3.14 malpractice RVUs based on the 2025 Medicare fee schedule.

What is the difference between CPT 23466 and 29806?

CPT 23466 is an open surgical repair of the shoulder capsule requiring a skin incision and direct visualization, while 29806 is an arthroscopic capsulorrhaphy performed through small portals with a camera. The open approach (23466) typically reimburses higher and is used for more extensive capsular reconstruction.

Can CPT 23466 be billed with a rotator cuff repair code?

CPT 23466 may be billed with rotator cuff repair codes if separate and distinct pathology exists, but CCI edits often bundle these procedures. Modifier 59 with detailed documentation showing independent capsular insufficiency requiring separate repair is typically required to obtain separate payment.

Is modifier LT or RT required for billing CPT 23466?

Yes, laterality modifiers LT (left) or RT (right) are mandatory when billing CPT 23466 as it is a bilateral procedure code. Claims submitted without the appropriate laterality modifier will be automatically denied by Medicare and most commercial payers.

What documentation is needed to support medical necessity for CPT 23466?

Medical necessity documentation should include imaging studies (MRI or CT arthrogram) showing capsular pathology, evidence of recurrent shoulder instability or dislocation, documentation of failed conservative treatment (physical therapy for 3-6 months, activity modifications), and clinical examination findings demonstrating glenohumeral instability.

Does CPT 23466 have a global period for postoperative care?

Yes, CPT 23466 has a 90-day global surgical period, meaning routine postoperative care for 90 days following the procedure is included in the reimbursement and cannot be billed separately. Unrelated E/M services during this period require modifier 24.