Summary & Overview
CPT 23412: Open Repair of Chronic Rotator Cuff Rupture
CPT code 23412 is a nationally recognized billing code for the open surgical repair of chronic ruptured musculotendinous cuffs, most commonly the rotator cuff. This procedure is a cornerstone in orthopedic surgery, providing relief and improved function for patients suffering from chronic shoulder injuries. The code is typically utilized in outpatient hospital settings, reflecting advancements in surgical techniques and patient care.
Major payers covering this procedure include Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. Understanding coverage policies and reimbursement benchmarks for these payers is essential for healthcare organizations, clinicians, and billing professionals. The publication offers insights into payer-specific coverage, common billing modifiers such as 51 for multiple procedures and 59 for distinct procedural services, and associated clinical taxonomies relevant to orthopedic surgery.
Readers will gain a comprehensive overview of the clinical context for CPT code 23412, including its relationship to common ICD-10 diagnoses for rotator cuff tears and ruptures. The article also highlights related CPT codes, such as 23130, to provide a broader perspective on shoulder repair procedures. Policy updates, coding benchmarks, and payer coverage details are presented to inform stakeholders about current trends and requirements in orthopedic surgical billing.
CPT Code Overview
CPT code 23412 describes the open surgical repair of a ruptured musculotendinous cuff, such as the rotator cuff, specifically for chronic cases. This procedure is a key intervention in orthopedic surgery, addressing persistent shoulder injuries that impact mobility and function. The typical site of service for this procedure is an outpatient hospital setting, designated as Place of Service 22. The code is used to identify and bill for the surgical restoration of shoulder integrity in patients with chronic rotator cuff ruptures.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult presenting with chronic shoulder pain and weakness, often following months of limited mobility and failed conservative treatments such as physical therapy or corticosteroid injections. Imaging studies, such as MRI or ultrasound, confirm a chronic rotator cuff tear or rupture. The orthopedic surgeon evaluates the patient in an outpatient hospital setting (Place of Service 22) and determines that open surgical repair is indicated. The procedure coded as 23412 is performed to repair the ruptured musculotendinous cuff, restoring function and alleviating pain.
Coding Specifications
Common Modifiers:
| Modifier Code | Description | When Used |
|---|---|---|
51 | Multiple Procedures | Used when more than one procedure is performed during the same operative session. |
59 | Distinct Procedural Service | Used to indicate a procedure or service that is distinct or independent from other services performed on the same day. |
Associated Provider Taxonomies:
207X00000X- Orthopaedic Surgery Physician207XS0117X- Orthopaedic Surgery of the Spine Physician207XX0004X- Orthopaedic Trauma Physician
These taxonomies represent providers specializing in orthopedic surgery, including those focused on the spine and trauma cases.
Related Diagnoses
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M75.101- Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic- Relevant for patients with chronic, non-traumatic rotator cuff tears of the right shoulder undergoing repair.
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M75.102- Unspecified rotator cuff tear or rupture of left shoulder, not specified as traumatic- Used for chronic, non-traumatic rotator cuff tears of the left shoulder.
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M75.111- Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic- Indicates a partial tear of the right rotator cuff, suitable for surgical repair if conservative management fails.
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M75.112- Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic- Represents a partial tear of the left rotator cuff, relevant for surgical intervention.
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M75.121- Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic- Used for patients with a full-thickness tear of the right rotator cuff, often requiring open repair.
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M75.122- Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic- Applies to full-thickness tears of the left rotator cuff, indicating need for surgical repair.
Related CPT Codes
23130- Excision Procedures on the Shoulder (partial acromioplasty or acromionectomy with or without coracoacromial ligament release)
Clinical Relationship:
23130is often performed in conjunction with23412during rotator cuff repair to address impingement or optimize the surgical outcome. It may be coded together with appropriate modifiers, such as51for multiple procedures.23130can also be used as an alternative procedure if acromial pathology is present without the need for rotator cuff repair.
National Reimbursement Benchmarks
Nationally, the mean rate for CPT code 23412 under Medicare is $806.06, while the BUCA (Blue Cross Blue Shield, UnitedHealth Group, Cigna, and Aetna) average commercial mean rate is $1,126.33. This highlights a substantial gap between Medicare and commercial payer reimbursement levels for this procedure.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare shows the tightest range at $67.00, indicating relatively consistent rates. In contrast, UnitedHealth Group exhibits the widest dispersion at $866.00, reflecting greater variability in commercial reimbursement. Cigna and Blue Cross Blue Shield also display broad ranges, while Aetna's rates are more tightly clustered.
The table and chart below present the full breakdown of national benchmarks for each payer, including mean rates and percentile values.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.