2022 ASC Coding Tips: Rotator Cuff Repairs

By Kris Brown, RHIT, CPC, CPMA, CASCC, Senior Coding & Auditing Manager

Rotator cuff repairs have different documentation requirements based on the approach. Let’s look at the scenarios coders may encounter and what surgeons should include in their documentation.

Arthroscopic rotator cuff repairs are always reported identically. Whether the tear is acute or chronic, it is coded as follows:

29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair

Open rotator cuff repairs require the documentation to indicate whether the tear is acute or chronic. Open rotator cuff repairs are coded as follows:

23410 – Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute

23412 – Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic

Coders often assume that the length of time the injury has been present is indicative of chronic versus acute. However, this is not the case. If the tear was caused by an injury/trauma, it is considered acute regardless of how long ago the injury occurred. [1] If this information is not supported in the operative report, the coder will need to query the surgeon for more details.

Chronic rotator cuff tears occur over time by overuse and are often involved with other chronic shoulder conditions, such as arthritis.

As with the CPT codes, ICD-10-CM codes for rotator cuff tears are dependent on the cause of the tear. These codes are as follows:

• If an injury/trauma is documented, S46.01- is reported based on indexing (tear>rotator cuff>traumatic).
• If an injury or trauma is not documented, default indexing leads to M75.1- (tear>rotator cuff).
• If the documentation supports a complete/full thickness tear, indexing leads to M75.12-.
• If the documentation supports a partial/incomplete tear, indexing leads to M75.11-.
• If the documentation does not support the completeness/thickness, M75.10- is reported.