Summary & Overview
CPT 23395: Muscle Transfer to Shoulder or Upper Arm
CPT code 23395 denotes a reconstructive surgical procedure in which a surgeon transfers a muscle from another part of the patient’s body to the shoulder or upper arm to restore upper-extremity function after injury or muscle loss. This code captures an important category of limb-sparing and function-restoring operations that influence postoperative rehabilitation needs, resource utilization in the operating room, and long-term functional outcomes for patients with complex shoulder and arm injuries. Nationally, the procedure is relevant for trauma, brachial plexus, and reconstructive surgery care pathways.
Key payers referenced in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise review of what CPT code 23395 represents clinically, typical sites of service, and the payer landscape covered. The publication also outlines benchmarking topics, common modifier usage context (listed separately), and clinical context required for coding and claims review. The material is intended to help billing managers, coding specialists, and policy analysts understand where this code fits in surgical service lines and payer coverage frameworks. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 23395 describes a surgical procedure in which a muscle is transferred from another site in the patient's body to the shoulder or upper arm to restore or improve upper extremity function after damage to the native muscle. The operation addresses deficits caused by muscle loss, nerve injury, or trauma affecting shoulder or upper-arm function.
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Service type: Reconstructive muscle transfer surgery
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Typical site of service: Hospital operating room or ambulatory surgical center for operative management of upper-extremity dysfunction
Clinical & Coding Specifications
Clinical Context
A typical patient is a 45-year-old manual laborer with chronic shoulder dysfunction after a traumatic brachial plexus injury that resulted in irreversible loss of function of the deltoid and portions of the rotator cuff. The patient presents with marked weakness of shoulder abduction and external rotation, pain, and functional impairment in activities of daily living. Nonoperative measures including physical therapy, bracing, and pain management have been exhausted. Imaging (MRI, EMG) confirms denervation or irreparable muscle/tendon damage. The orthopedic surgeon and multidisciplinary team (anesthesiology, physical therapy) evaluate the patient, obtain informed consent, and schedule an open operative transfer of an autologous muscle (for example, latissimus dorsi or pectoralis major transfer) to the shoulder/upper arm to restore function. The perioperative workflow includes preoperative templating, intraoperative neurovascular monitoring as indicated, operative muscle harvest and transfer, tendon fixation to restore biomechanics, and postoperative immobilization with a structured rehabilitation protocol starting with passive range of motion progressing to active strengthening over months. Typical site of service is an inpatient or outpatient hospital operating room or ambulatory surgery center depending on patient comorbidities and anticipated postoperative care.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when reporting only the physician’s professional services separate from technical facility charges (rare for this operative procedure when global surgery billing applies). |