Summary & Overview
CPT 23440: Biceps Tenodesis for Shoulder Stabilization
CPT code 23440 identifies a surgical procedure that resects or transposes the long head of the biceps tendon and secures it at a new attachment to improve shoulder stability. The procedure is commonly performed by orthopedic surgeons to address biceps tendon pathology that contributes to glenohumeral instability and related shoulder dysfunction. This code is relevant nationally because it captures a commonly billed operative service in musculoskeletal care and factors into surgical quality, resource utilization, and payment policy discussions.
Key payers addressed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical description, typical sites of service (hospital operating room and ambulatory surgery center), and the service type (orthopedic surgical procedure). The publication outlines benchmark considerations, common modifier usage patterns where available, and the clinical context that influences coding and billing for this shoulder stabilization procedure. It also summarizes implications for coverage and reimbursement policy at a national level and highlights areas where payer policy differences commonly arise. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 23440 describes a surgical procedure in which the long head of the biceps tendon is resected or transferred and fixed to a new attachment to improve shoulder stability. This operation addresses problems related to biceps tendon pathology and contributes to stabilization of the glenohumeral joint.
Service type: Surgical — Orthopedic shoulder procedure
Typical site of service: Hospital operating room or ambulatory surgery center
Clinical & Coding Specifications
Clinical Context
A 52-year-old recreational athlete presents with chronic anterior shoulder pain, weakness with overhead activities, and symptomatic instability after a partial rotator cuff tear and long head of biceps tendon pathology. Conservative care including physical therapy, activity modification, and corticosteroid injection failed to relieve symptoms. Imaging (MRI) demonstrates tendinopathy and subluxation of the long head of the biceps with associated superior labral fraying. The orthopedic surgeon recommends surgical biceps tenodesis to resect or reattach the long head of the biceps tendon to a new anatomic location on the proximal humerus to reduce pain and improve shoulder stability.
The clinical workflow includes preoperative evaluation with history, physical exam, and imaging; informed consent; intraoperative arthroscopic or open tenodesis (resection and fixation of the long head of biceps); postoperative recovery with immobilization followed by staged physical therapy; and routine postoperative visits for wound checks and functional assessment. Typical documentation includes operative report describing approach (arthroscopic vs open), fixation method, laterality, concurrent procedures, anesthesia type, estimated blood loss, and immediate postoperative condition.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
RT | Right side | Use when the procedure is performed on the right shoulder |