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2025 CPT code 29828

Shoulder arthroscopy with biceps tenodesis.

Surgical endoscopy/arthroscopy always includes a diagnostic endoscopy/arthroscopy. When arthroscopy is performed in conjunction with arthrotomy, add modifier 51.If a cast is applied, its application and removal are included in the code.Subsequent replacement of the cast after the global period may be reported separately.

Modifiers may be appended to CPT code 29828 to indicate additional procedures performed during the same session (e.g., modifier 51 for multiple procedures), repeat procedures (modifier 76), or other qualifying circumstances.

Medical necessity for CPT code 29828 is established when a patient exhibits symptoms consistent with biceps tendon instability or tear, confirmed through clinical examination and imaging studies. The procedure is considered medically necessary when conservative treatment has failed to provide adequate pain relief or improve function.The extent of the surgical intervention should be justified by the severity of the pathology as documented in the medical record.

The orthopedic surgeon or qualified healthcare professional is responsible for performing the arthroscopy, evaluating the biceps tendon, performing the tenodesis (repair and reattachment), and ensuring proper closure of the incision.Preoperative and postoperative care may be billed separately, depending on the extent of services provided.

IMPORTANT:Do not report 29828 with 29805, 29820, 29822. For open biceps tenodesis, use 23430.

In simple words: The doctor uses a small camera (arthroscope) to look inside the shoulder joint and repair a damaged biceps tendon.This involves cleaning up or removing damaged parts of the tendon and reattaching the healthy part to the bone.

This CPT code encompasses surgical arthroscopy of the shoulder joint, specifically focusing on the biceps tendon.The procedure involves inserting an arthroscope into the shoulder joint to visualize and repair an unstable biceps tendon. This typically includes debridement of damaged tendon tissue and reattachment of the healthy portion to its bony insertion point on the humerus using appropriate surgical techniques. Saline solution may be used to inflate the joint and improve visualization.The procedure does not include open biceps tenodesis, which is coded separately (23430).

Example 1: A patient presents with chronic shoulder pain and instability due to a biceps tendon tear.Arthroscopy is performed to visualize the tear, debride the damaged tissue, and perform a tenodesis to stabilize the tendon., A patient suffers a traumatic shoulder injury with a partial tear of the biceps tendon.Arthroscopic repair is performed to reattach the damaged tendon and restore shoulder function., A patient has shoulder impingement syndrome with associated biceps tendon instability.Arthroscopy with biceps tenodesis is undertaken to address both conditions simultaneously.

* Preoperative diagnosis, including imaging studies (X-rays, MRI, CT scan) demonstrating the biceps tendon pathology.* Operative report detailing the arthroscopic findings, the technique used for biceps tenodesis, and the extent of tissue repair.* Postoperative progress notes documenting the patient's recovery and any complications.* Anesthesia records.

** The choice between arthroscopic and open techniques for biceps tenodesis depends on the extent and complexity of the tear, surgeon preference, and patient-specific factors.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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