How To Use CPT Code 23412

CPT code 23412 describes the open surgical repair of a chronic, or persistent, tear of the rotator cuff in the shoulder. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 23412?

CPT 23412 is used to describe the open surgical repair of a chronic, or persistent, tear of the rotator cuff in the shoulder. This code is specifically used when the provider performs an open treatment for a muscle tendon tear of the rotator cuff that has been present for a long time.

2. Official Description

The official description of CPT code 23412 is: ‘Repair of ruptured musculotendinous cuff (eg, rotator cuff) open chronic.’

3. Procedure

During the procedure for CPT 23412, the provider performs an open surgical repair of a chronic tear of the rotator cuff in the shoulder. The patient is appropriately prepped and anesthetized before the procedure begins. The provider makes an incision in the skin of the outer side of the shoulder, in line with the deltoid muscle fibers. They then dissect down through the subcutaneous tissue, or just under the skin, and retract the muscles, blood vessels, and nerves to expose the subacromial space. This space is located between the acromion process of the shoulder blade and the head of the humerus bone.

Once the provider has access to the rotator cuff muscles and the tear, they assess the shape of the tear and remove any frayed segments of the tendons. They then create a trench in the humeral bone for the tendon to lie in and drill holes in the bone to attach the tendon. The tear in the tendon is sutured, and bone anchors are placed to fix the tendon to the bones. The provider ensures that all bleeding is stopped, closes the wound by suturing the layers of tissue together, and applies a dressing.

4. Qualifying circumstances

CPT 23412 is used for the open surgical repair of a chronic tear of the rotator cuff. It is important to note that this code should only be used for chronic tears, not acute tears. Chronic tears refer to tears that have been present for a long time and have a lasting effect. Acute tears, on the other hand, have a rapid onset or short course.

5. When to use CPT code 23412

CPT code 23412 should be used when the provider performs an open surgical repair of a chronic tear of the rotator cuff. It is important to ensure that the tear is chronic and not acute, as there is a separate code for the open treatment of acute tears (CPT code 23410).

6. Documentation requirements

To support a claim for CPT 23412, the provider must document the following information:

• Patient’s diagnosis of a chronic tear of the rotator cuff
• Details of the surgical procedure performed, including the incision, dissection, repair of the tear, and closure of the wound
• Any additional procedures or techniques used during the surgery
• Any complications or unexpected findings during the procedure
• Signature of the provider performing the surgery

7. Billing guidelines

When billing for CPT 23412, ensure that the procedure performed is an open surgical repair of a chronic tear of the rotator cuff. It is important to use the appropriate code based on the type of tear (chronic or acute). CPT code 23410 should be used for the open treatment of acute tears, while CPT code 23412 is specifically for chronic tears.

8. Historical information

CPT code 23412 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 23412

There are several similar codes to CPT 23412 that are used for different procedures on the shoulder. These include:

• CPT 23395: Repair of ruptured musculotendinous cuff (eg, rotator cuff) open acute
• CPT 23397: Repair of ruptured musculotendinous cuff (eg, rotator cuff) open acute with tendon graft
• CPT 23410: Repair of ruptured musculotendinous cuff (eg, rotator cuff) open acute
• CPT 23420: Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)
• CPT 23430: Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty); with coracoacromial ligament transfer

9. Examples

1. A patient undergoes open surgical repair of a chronic tear of the rotator cuff in their right shoulder.
2. A provider performs an open treatment for a persistent tear of the rotator cuff in a patient’s left shoulder.
3. An individual undergoes an open surgical repair of a long-standing tear of the rotator cuff in their dominant shoulder.
4. A chronic tear of the rotator cuff in the right shoulder is repaired through an open surgical procedure.
5. A provider performs an open treatment for a persistent tear of the rotator cuff in a patient’s non-dominant shoulder.
6. An individual undergoes an open surgical repair of a chronic tear of the rotator cuff in their left shoulder.
7. A patient’s chronic tear of the rotator cuff in their dominant shoulder is repaired through an open surgical procedure.
8. A provider performs an open treatment for a long-standing tear of the rotator cuff in a patient’s right shoulder.
9. An individual undergoes an open surgical repair of a persistent tear of the rotator cuff in their non-dominant shoulder.
10. A chronic tear of the rotator cuff in the left shoulder is repaired through an open surgical procedure.