2025 CPT code 23412
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Musculoskeletal System Musculoskeletal System Feed
Open surgical repair of a chronic rotator cuff tear in the shoulder.
Modifiers 54, 76, and 77 may be used as applicable. Refer to the CPT manual for specific modifier usage guidelines.
Medical necessity is established by the presence of a significant, symptomatic chronic rotator cuff tear that impairs shoulder function and does not respond to conservative management (e.g., physical therapy, medication).The severity and impact on daily activities must be documented.
The orthopedic surgeon is responsible for all aspects of the surgery, from pre-operative assessment and planning to the post-operative care and follow-up. This includes preparing the patient, making the incision, repairing the rotator cuff tear using appropriate techniques (such as suturing and bone anchoring), controlling bleeding, and closing the wound. The surgeon also monitors the patient's recovery and addresses any complications that may arise.
In simple words: This code describes an operation to fix a long-standing tear in the rotator cuff (a group of muscles that support the shoulder). The surgeon makes an incision, accesses the torn muscle, cleans up the damaged area, and stitches it back together, often using anchors to secure the repair. This is for chronic (long-lasting) tears, not sudden ones.
This CPT code encompasses the open surgical repair of a chronic or persistent tear in the rotator cuff of the shoulder.The procedure involves an incision on the outer shoulder, dissection through subcutaneous tissue, retraction of muscles, blood vessels, and nerves to expose the subacromial space.The provider assesses the tear, removes frayed tendon segments, creates a humeral bone trench for tendon placement, drills bone holes for tendon attachment, sutures the tear, secures the tendon with bone anchors, controls bleeding, and closes the wound.This code is specifically for chronic tears; acute tears are coded differently.
Example 1: A 55-year-old female presents with chronic right shoulder pain and weakness, diagnosed with a full-thickness rotator cuff tear via MRI.Open repair is performed using 23412., A 60-year-old male with a history of shoulder impingement develops a chronic rotator cuff tear confirmed by physical exam and imaging. Open repair is undertaken, and 23412 is used., A 48-year-old construction worker sustains a chronic rotator cuff tear due to repetitive overhead work.Arthroscopy is ruled out due to the size and complexity of the tear. Open repair is chosen, and 23412 is reported.
* Preoperative diagnosis (e.g., MRI, physical exam findings, patient history)* Operative report detailing surgical technique and findings* Anesthesia record* Postoperative progress notes* Imaging studies (if applicable)
** This code should only be used for open surgical repair of chronic rotator cuff tears.It does not include arthroscopic procedures or repairs of acute tears.Careful documentation is essential to support the use of this code.
- Revenue Code: P3D (MAJOR PROCEDURE, ORTHOPEDIC - OTHER)
- Payment Status: Active
- Specialties:Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Outpatient Hospital