Soft tissue repair · Shoulder

23000

Open surgical removal of calcium deposits located beneath the deltoid muscle in the shoulder (subdeltoid region).

Verified May 8, 2026 · 6 sources ↓

Medicare
$571.49
Total RVUs
17.11
Global, days
90
Region
Shoulder
Drawn from CMSAAPCAAOS

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 6 cited references ↓

  • Operative note must explicitly state 'open' approach — needle or arthroscopic techniques are not billable under 23000
  • Describe the location of deposits (subdeltoid bursa, rotator cuff surface, tendon substance) and their gross appearance
  • Document laterality (left, right, or bilateral) in both the operative note and the diagnosis
  • If modifier 22 is used, quantify the additional work: dense, calcified, or adherent deposits with extended dissection time
  • If a concurrent rotator cuff repair is performed, document that as a separate, distinct surgical step with its own description
  • Preoperative imaging (X-ray or ultrasound) confirming calcific deposit should be in the record to support medical necessity

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 23000 covers open excision of calcific deposits from the subdeltoid space of the shoulder — typically calcium hydroxyapatite accumulations associated with calcific tendinitis of the rotator cuff. The surgeon makes a direct incision, identifies the deposit, and evacuates the calcium material, which may be chalky, toothpaste-like, or hardened depending on disease phase. This is an open procedure; needle aspiration, barbotage, or arthroscopic lavage of calcific deposits are not reported with 23000.

The 90-day global period means all routine postoperative care — including wound checks, dressing changes, and suture removal — is bundled through day 90. If the surgeon elects to perform concomitant rotator cuff repair at the same session, that carries its own separately reportable code, but NCCI bundling rules apply and modifier use must be supported by distinct operative documentation. Same-day E/M visits require modifier 25 to be separately reimbursed.

Calcific tendinitis deposits are almost always unilateral, but bilateral presentation occurs. If both shoulders are addressed in the same operative session, append modifier 50 (or LT/RT on separate lines per payer preference). Laterality should always be specified in the claim and operative note — payers routinely flag shoulder procedures submitted without side designation.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU4.37
Practice expense RVU12.04
Malpractice RVU0.7
Total RVU17.11
Medicare national rate$571.49
Global period90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

SettingMedicare rate (national)
Office (PFS non-facility)
Procedure performed in physician's office
$571.49
HOPD (APC 5073)
Hospital outpatient department
$2,967.63
ASC (PI A2)
Ambulatory surgical center (freestanding)
$1,248.36

Common denial reasons

The recurring reasons claims for CPT 23000 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

  • Missing or ambiguous laterality — claims submitted without LT or RT are frequently rejected or pended
  • Procedure coded as open (23000) when the operative note describes needle aspiration, barbotage, or arthroscopic lavage
  • Lack of preoperative imaging documentation to establish medical necessity for surgical intervention
  • Same-day E/M billed without modifier 25, resulting in bundling denial
  • Bundling denial when a concurrent rotator cuff repair is reported without adequate documentation of a distinct surgical component

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01Can I bill 23000 for ultrasound-guided needle aspiration or barbotage of a calcific deposit?
No. 23000 is strictly an open procedure. Needle aspiration or barbotage — with or without ultrasound guidance — requires a different coding pathway. Using 23000 for a percutaneous technique is incorrect and will not hold up to audit.
02If the surgeon performs calcific deposit removal and a rotator cuff repair in the same session, how do I code it?
Report the rotator cuff repair code (e.g., 23410 or 23412) as the primary procedure and 23000 separately with modifier 59 or XS if payer policy supports unbundling. Check current NCCI PTP edits before submitting — bundling relationships between these codes are payer-variable and need to be confirmed against active edits.
03What global period applies to 23000, and what does that mean for post-op visits?
23000 carries a 90-day global period. All routine post-op care through day 90 — wound checks, suture removal, standard dressing changes — is bundled. Separately billing a post-op visit in that window requires modifier 24 (unrelated E/M) or modifier 79 (unrelated procedure), with documentation that the visit was not for the surgical condition.
04How do I bill if both shoulders are treated in the same operative session?
Append modifier 50 for bilateral billing on a single line, or submit on two lines with LT and RT per your payer's preference. Medicare generally accepts modifier 50 on one line; many commercial payers prefer separate lines. Verify with each payer before submitting.
05When is modifier 22 justified for CPT 23000?
Modifier 22 applies when the work is substantially greater than typical — for example, dense, calcified deposits adherent to the rotator cuff requiring extended dissection, or unusual anatomy from prior surgery. The operative note must describe the specific challenge and increased time or effort. A generic note stating 'difficult case' will not support the modifier on audit.
06Is there an HOPD vs. ASC payment difference for 23000, and does site of service affect coding?
Yes — HOPD and ASC payments differ materially (see the Site of Service comparison on this page). The CPT code itself does not change by site, but if billing the professional component from a facility, do not append modifier 26; 23000 is a surgical procedure code, not a diagnostic service split into TC and 26 components.

Mira AI Scribe

Mira's AI scribe captures the surgical approach (open incision vs. needle or scope), deposit location within the subdeltoid space, gross deposit characteristics, and explicit laterality from the surgeon's dictation. It flags operative notes that omit the word 'open' or fail to specify side — the two documentation gaps most likely to trigger a medical necessity denial or payer pend on 23000 claims.

See how Mira captures CPT 23000 documentation

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