Orthopedic Coding Alert

Question: Are there any authoritative guidelines on when to use 23420?

Rhode Island Subscriber

Answer: The AMA's CPT Assistant (October 2005) states that 23420 (Reconstruction of complete shoulder [rotator] cuff avulsion, chronic [includes acromioplasty]) "is intended to identify an old tear." This guidance simply states the descriptor's "chronic" requirement in a different way. Your surgeon should document that the problem is more than three months old for you to consider it chronic.

CPT Assistant goes on to state, "This type of extreme tear usually requires rearrangement of the normal anatomy and sometimes grafting with either biological or nonbiological material for repair." Again the guidance is expanding on the descriptor's "reconstruction" and "complete" requirements. CPT Assistant is authoritative because it is from the AMA, which publishes the CPT codes.

In addition, the February 2002 CPT Assistant advises using 23420 when orthopedists repair "all three major muscles/tendons of the shoulder cuff."

Although not authoritative, the American Academy of Orthopedic Surgeons- April 2004 Bulletin, Accurately Code Shoulder Procedures, states, "If there is significant retraction with a large tear, extensive releases and mobilization may be required, justifying the use of code 23420. If fascia or synthetic material is required, code 23420 is also appropriate."

-- Reader Questions and You Be the Coder were reviewed by Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC; and Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.