Patient presents for an arthroscopic subacromial decompression, mini-open rotator cuff repair and biceps tendon debridement for chronic rotator cuff tear. We are aware that the shoulder joint is considered a contiguous structure.
However, would it be appropriate to report the open and arthroscopic codes for the procedures performed? Also, is it appropriate to report the debridement of the biceps tendon with the other procedures that were performed?
Based on the operative report submitted, the procedure was performed on the shoulder which is a single structure and procedures performed on the same structure would not be reported separately.
Therefore, assign CPT code 23412, Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; chronic, for the mini-open rotator cuff repair. No additional code would be reported for the tendon debridement and the other arthroscopic procedures performed as they would be considered inherent to the open rotator cuff repair.