Open reconstruction of a complete, chronic rotator cuff avulsion with acromioplasty included

Verified May 8, 2026 · 6 sources ↓

Medicare: $906.50
Total RVUs: 27.14
Global, days: 90
Region: Shoulder

Drawn from CMSAAPCFacultyEmedny

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 6 cited references ↓

Explicit documentation that the tear is chronic — generally accepted as greater than three months in duration
Description of completeness: all three major rotator cuff muscles/tendons involved in the avulsion
Documentation of significant retraction requiring extensive mobilization, releases, or anatomic rearrangement
Specify whether fascia, allograft, xenograft, or synthetic graft material was used — supports 23420 over 23412
Named surgical approach (e.g., deltoid-splitting, deltoid-detaching) — 'standard approach' flags audits
Acromioplasty described in operative note; do not bill it separately as it is included in 23420
Laterality documented (left vs. right shoulder) to support modifier LT or RT

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 25 Significant separate E/M 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 57 Decision for surgery 58 Staged or related 59 Distinct service 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

23420 covers open reconstruction of a complete rotator cuff avulsion that is chronic in nature — meaning the tear is generally considered more than three months old. Acromioplasty is bundled into this code and cannot be billed separately. The procedure typically involves rearrangement of normal shoulder anatomy, extensive tendon mobilization and release, and often the use of fascia, allograft, or synthetic graft material to bridge the defect. All three major rotator cuff muscles/tendons are involved.

This code sits above 23410 (acute open repair) and 23412 (chronic open repair) on the severity spectrum. Use 23420 when the operative note documents complete avulsion with significant retraction, extensive soft-tissue releases, and/or grafting. A note that simply describes a multi-tendon repair without documenting those elements won't support 23420 on audit — coders should query the surgeon before assuming the upgrade.

The 90-day global period covers all routine post-op care through day 90. Separate E/M visits during that window require modifier 24 (unrelated) or 25 (same-day, separately identifiable). Unplanned returns to the OR for a related complication use modifier 78; an unrelated procedure in the global window uses modifier 79.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	13.2
Practice expense RVU	11.17
Malpractice RVU	2.77
Total RVU	27.14
Medicare national rate	$906.50
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$906.50
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI J8) Ambulatory surgical center (freestanding)	$4,698.20

Common denial reasons

The recurring reasons claims for CPT 23420 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Upcoding from 23412 — operative note describes chronic multi-tendon repair but lacks documentation of complete avulsion, significant retraction, or grafting that distinguishes 23420
Separate billing of acromioplasty (23415 or arthroscopic equivalent) — it is bundled into 23420 and will be denied as a component
Missing or insufficient chronicity documentation — payers require evidence the tear is chronic; acute or subacute presentations do not support 23420
Modifier absent when billing a related procedure during the 90-day global period — claim denied without modifier 78 or 79
Laterality modifier missing (LT/RT) — many payers require it for unilateral shoulder procedures

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01What separates 23420 from 23412?

23412 covers open repair of a chronic rotator cuff tear. 23420 requires a complete avulsion — all three major cuff tendons — with significant retraction, extensive anatomic rearrangement, and often grafting. If the note doesn't document those elements, 23412 is the correct code regardless of what the surgeon circles on the charge sheet.

02Is acromioplasty separately billable with 23420?

No. Acromioplasty is explicitly included in the 23420 descriptor. Billing 23415 or an arthroscopic acromioplasty code alongside 23420 will generate a bundling denial. Do not unbundle it.

03Can 23420 be billed with a tendon transfer code?

Yes. If a tendon transfer was separately performed, 23397 (multiple muscle transfers) may be added with modifier 59 to indicate a distinct procedure. The operative note must describe the transfer as a separate, additive step beyond the reconstruction itself.

04How do you define 'chronic' for 23420 purposes?

CPT Assistant (October 2005) states the tear must be an 'old tear.' The generally accepted threshold is greater than three months. Document symptom duration, imaging history, and any prior conservative management in the operative or pre-op note.

05What modifiers are needed when performing 23420 during a global period for a prior shoulder surgery?

If the return is for a complication related to the original procedure, use modifier 78. If the new procedure is unrelated to the original surgery, use modifier 79. Never use modifier 78 for an unrelated procedure — that inversion is a common audit finding.

06Is 23420 ever performed arthroscopically?

No. 23420 is an open procedure by definition. Some third-party content mislabels it as arthroscopic — that is incorrect. Arthroscopic rotator cuff repair maps to the 29827 code family, not 23420.

07What ICD-10 diagnosis codes typically support 23420?

M75.1xx (rotator cuff syndrome/tear) and S46.0xx series (injury of rotator cuff) are common. The diagnosis code should reflect a complete, chronic tear. Acute traumatic tear codes will create a mismatch with 23420's chronic descriptor and may trigger a denial.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the surgeon's dictation for chronicity (duration of symptoms, prior failed conservative treatment), tear completeness (all three major cuff tendons involved), degree of retraction, mobilization techniques performed, and graft material used if any. This prevents the most common audit flag for 23420 — an operative note that describes the repair but omits the clinical elements that distinguish a complete chronic avulsion reconstruction from a standard chronic repair under 23412.

See how Mira captures CPT 23420 documentation