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Coding tip: Determine active versus chronic tears in order to code rotator cuff tears

Ambulatory Surgery Reimbursement Update, October 30, 2007

Shoulders are subject to a lot of wear and tear and/or degeneration, due to the constant use of our arms in our daily activities. A torn rotator cuff is a very painful injury and creates a very weak shoulder. Acute injuries can occur from trauma such as a fall, or as injuries from sports. Chronic tears stem from overuse or constant stress. The rotator cuff is formed by the tendons of four muscles:

• The Supraspinatus
• The Infraspinatus
• Teres Minor
• The Subscapularis

The poor blood supply in the rotator cuff makes these tendons especially vulnerable to degeneration from normal aging. Acute versus chronic tears, and the CPT codes that support them, is the cause of much coding confusion. The acute CPT code 23410 for an open repair describes the repair for an acute rupture, while the 23412 open code describes the repair of a chronic rupture. If this is not documented in the operative report, check the History and Physical for additional information that could identify whether or not the problem/condition/injury is due to an injury, trauma or degenerative problem. If the tear is a "complete tear", bill CPT code 23420 for an extensive rotator cuff avulsion injury if properly documented (meaning the shoulder must have tears of at least 3 of 4 of the rotator cuff tendons). When the procedure is performed arthroscopically, use CPT code 29827.

This tip is brought to you by Ellis Medical Consulting, Inc.

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