Arthroscopy, shoulder, surgical; with rotator cuff repair
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Failed conservative treatment not documented for at least 3-6 months
Very Common23472 (arthroscopic rotator cuff repair) denials occur when documentation doesn't show adequate trial of conservative treatment. Most insurance policies require documented failure of physical therapy, NSAIDs, activity modification, and corticosteroid injection for 3-6 months before approving surgery for chronic tears.
Common Causes
- • Surgery requested without PT trial documented
- • PT attendance incomplete - only 2-3 visits instead of 6-12 weeks
- • No documentation of steroid injection trial
Resolution Strategy
Appeal with comprehensive documentation: PT records showing 6-12 weeks participation (attendance dates, exercises prescribed, lack of improvement in ROM/strength), trial of NSAIDs (medication names, dosages, duration), activity modification attempts (work restrictions, lifestyle changes), at least one corticosteroid injection (date, response, how long relief lasted). If acute traumatic tear in active individual, may argue surgery appropriate without extended conservative trial. If truly no conservative treatment attempted, delay surgery for 3-month trial, document failure, then resubmit authorization.
2. MRI not submitted showing full-thickness rotator cuff tear
Very CommonInsurance requires MRI or ultrasound confirmation of rotator cuff tear before approving surgical repair. Denials occur when imaging not submitted with authorization request, or when imaging shows partial tear not meeting threshold for repair (typically <50% thickness).
Common Causes
- • MRI not sent with authorization request - only clinical notes submitted
- • MRI shows partial-thickness tear <50% - debridement more appropriate than repair
- • MRI >1 year old - insurance wants current imaging
Resolution Strategy
Submit complete MRI report and images showing: full-thickness tear (tendon disruption from articular to bursal surface), tear size in cm, tendons involved (supraspinatus, infraspinatus, subscapularis, teres minor), muscle atrophy (if present), and date of imaging <12 months old. If partial tear, appeal arguing: >50% partial tear with failed conservative treatment, or progression from prior imaging showing increasing tear size. Most successful when imaging clearly shows full-thickness tear requiring repair.
3. Bundling denial - acromioplasty (29826) billed separately with rotator cuff repair
Common23472 (rotator cuff repair) includes diagnostic arthroscopy, debridement, and acromioplasty when performed as part of rotator cuff repair. Insurance denies 29826 (acromioplasty) when billed separately unless clearly distinct procedure (e.g., performed on different shoulder).
Common Causes
- • Acromioplasty billed separately - bundled into 23472
- • Subacromial decompression performed during rotator cuff repair - included
- • Billing software auto-populates both codes from operative report
Resolution Strategy
Bundling denial is correct - do not appeal unless acromioplasty performed on different shoulder (bill with RT/LT modifiers). Acromioplasty reimbursement included in 23472 RVU calculation. Only bill 29826 separately if distinct procedure: different shoulder, or performed different operative session, or documented as completely separate indication (e.g., shoulder impingement without rotator cuff tear). In most cases, accept bundling denial and do not rebill separately.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Arthroscopic repair of torn rotator cuff tendon(s) in the shoulder
Common Scenarios
Documentation Requirements
- MRI or ultrasound confirming rotator cuff tear
- Documentation of failed conservative treatment (PT, NSAIDs, injections)
- Tear size, location, and number of tendons involved
- Operative report describing repair technique and anchors used
- Pre-operative range of motion and strength testing
Coding Guidelines
Common Modifiers
Bundling Rules
- Includes diagnostic arthroscopy, debridement, and acromioplasty if performed
- Suture anchors and implants separately billable with supply codes
- Cannot bill 29826 (acromioplasty) separately unless distinct
- Post-operative physical therapy separately billable after global period
Exclusions
- Do not use for partial rotator cuff debridement only (use 29827)
- Cannot bill with open rotator cuff repair (23410) for same session
- Do not use if no actual repair performed (diagnostic scope only = 29805)
- Cannot bill for simple subacromial decompression without repair
Coding Notes
Related CPT Codes
Clinical scenarios
- MRI or ultrasound confirming rotator cuff tear
- Documentation of failed conservative treatment (PT, NSAIDs, injections)
- Tear size, location, and number of tendons involved
- MRI or ultrasound confirming rotator cuff tear
- Documentation of failed conservative treatment (PT, NSAIDs, injections)
- Tear size, location, and number of tendons involved
- MRI or ultrasound confirming rotator cuff tear
- Documentation of failed conservative treatment (PT, NSAIDs, injections)
- Tear size, location, and number of tendons involved
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Medicare Pricing
PFSRVU Breakdown
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Ask a QuestionFrequently Asked Questions
CPT 23472 is the billing code for "Arthroscopy, shoulder, surgical; with rotator cuff repair". Arthroscopic repair of torn rotator cuff tendon(s) in the shoulder
Medicare pays approximately $1414.84 for CPT 23472 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 23472 has a total RVU of 58.50, broken down as: Work RVU 15.80, Practice Expense RVU 38.20, and Malpractice RVU 4.50. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 23472 is "Failed conservative treatment not documented for at least 3-6 months". 23472 (arthroscopic rotator cuff repair) denials occur when documentation doesn't show adequate trial of conservative treatment. Most insurance policies require documented failure of physical therapy, NSAIDs, activity modification, and corticosteroid injection for 3-6 months before approving surgery for chronic tears. Common causes include: Surgery requested without PT trial documented; PT attendance incomplete - only 2-3 visits instead of 6-12 weeks. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 23472 include: MRI or ultrasound confirming rotator cuff tear; Documentation of failed conservative treatment (PT, NSAIDs, injections); Tear size, location, and number of tendons involved; Operative report describing repair technique and anchors used. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 23472: Includes diagnostic arthroscopy, debridement, and acromioplasty if performed. Suture anchors and implants separately billable with supply codes Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 23472 include: 50 (Bilateral procedure (rare)), RT (Right shoulder), LT (Left shoulder). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 23472 is 90-150 minutes depending on tear size and complexity. Time-based codes require documentation of the actual time spent providing the service.