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. |