Rotator Cuff Repair (Arthroscopic)
2982729826wRVU: 2.93 — Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty (true CPT add-on to 29827; 2.93 wRVU; ZZZ global — separately reportable with 29827; no current NCCI edit bundles 29826 with 29827; AAOS Global Service Data Guide supports separate payment)
Right [left] [full-thickness / partial-thickness] rotator cuff tear, [supraspinatus / infraspinatus / subscapularis / teres minor], confirmed on MRI
Same
Right [left] arthroscopic rotator cuff repair, [single-row / double-row / transosseous equivalent] technique [with acromioplasty / biceps tenotomy / biceps tenodesis]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal with interscalene nerve block
The patient is a [age]-year-old [male/female] with a [full-thickness / partial-thickness] rotator cuff tear confirmed on MRI, presenting with refractory shoulder pain and weakness after [X weeks/months] of conservative management including physical therapy. The risks, benefits, and alternatives were discussed and informed consent was obtained.
Arthroscopic examination of the glenohumeral joint demonstrated a [X]-cm [full-thickness / partial-thickness] tear of the [supraspinatus / infraspinatus] at the [footprint / musculotendinous junction] (Cofield classification: [small <1 cm / medium 1–3 cm / large 3–5 cm / massive >5 cm]). The tear was [mobile / retracted to the glenoid rim] with [minimal / moderate / significant] muscle atrophy on pre-operative MRI (Goutallier Grade [0–4]). The biceps tendon was [normal / frayed / subluxed / with SLAP tear]. [The subscapularis was intact. / A [full-thickness / partial-thickness upper-third] subscapularis tear was identified.] The articular surface demonstrated [intact cartilage / Outerbridge Grade [I–IV] changes at the humeral head / glenoid].
The patient was positioned in the [lateral decubitus / beach chair] position with the operative arm in [traction / supported]. Standard posterior viewing and anteromedial working portals were established. A lateral subacromial working portal was created for cuff repair access. Diagnostic arthroscopy was performed of the glenohumeral joint.
The subacromial space was entered through the posterior portal. Bursectomy was performed to visualize the rotator cuff tear. The tear was characterized: [X] cm in [AP / ML] dimension. Tear edges were prepared with a shaver and electrocautery. The footprint was decorticated with a burr to create a bleeding bone surface.
[Acromioplasty was performed: the subacromial space was evaluated. The anterior-inferior acromion was resected with a [4.5-mm] burr to a flat (Type I) contour, removing approximately [X] mm of bone. The coracoacromial ligament was released from the anterior acromion. The subacromial space was re-probed to confirm flat contour.]
[Single-row repair:]
[X] [5.5-mm] suture anchors were placed at the medial footprint. Sutures were passed through the tendon using a suture passer and tied arthroscopically with [Samsung Medical Center (SMC) / Weston] knots.
[Double-row / transosseous equivalent repair:]
Medial anchors were placed at the articular margin. Suture limbs were passed through the tendon. A lateral row of [4.75-mm] knotless anchors was placed at the lateral footprint, compressing the tendon to the greater tuberosity in a mattress configuration.
[Biceps tenotomy / tenodesis was performed: the biceps tendon was released from the superior labrum (CPT 29828). [For subpectoral tenodesis: a separate [3-cm] incision was made in the subpectoral region. The biceps tendon was identified and delivered. A bone tunnel was created in the proximal humerus and the tendon was secured with a [7-mm × 23-mm] interference screw.]]
Final arthroscopic views confirmed anatomic repair with secure anchor fixation and tendon coverage of the footprint. Portals were closed with [3-0 Monocryl]. A sling was applied.
None
None
Minimal
None
The patient was taken to the PACU in stable condition in a sling. Physical therapy with passive range of motion was initiated [on postoperative day 1 / within the first week per protocol]. Active-assisted ROM begins at approximately [4–6 weeks]. Strengthening begins at approximately [10–12 weeks]. Return-to-activity protocol was discussed.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left *** rotator cuff tear, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left arthroscopic rotator cuff repair, *** technique
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General + interscalene block
INDICATIONS: .PTAGE-year-old .PTSEX with *** rotator cuff tear, failed conservative management. Consent obtained.
FINDINGS: *** cm full/partial thickness tear, ***. Cofield: ***. Goutallier: Grade ***. Biceps ***. [Subscapularis intact / *** subscapularis tear.] Articular surface: Outerbridge *** at ***.
PROCEDURE:
*** position. Posterior/anteromedial/lateral portals. Diagnostic scope: findings above. Subacromial entry. Bursectomy. Tear *** cm. Footprint debrided and decorticated. [Acromioplasty: *** mm bone resected, flat contour confirmed.] Medial row: *** × *** mm anchors, sutures passed, tied. [Lateral row: knotless anchors.] [Biceps tenotomy/tenodesis performed.] Final scope: anatomic repair, footprint covered. Portals closed. Sling applied.
EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Sling. Passive ROM initiated POD 1 per protocol. Activity protocol reviewed.
Signed: .ME, .MYDEGREE
.TODAYVariants
Partial-Thickness Tear: Transtendinous Repair
The articular-sided partial-thickness tear involved [>50%] of the tendon thickness. Given the extent of tearing, in-situ repair was performed. The bursal surface was incised to convert the partial tear to a full-thickness defect to permit suture anchor repair. Alternatively, a transtendinous technique was used with anchor placement from the articular side without completing the tear. Partial tears involving <50% of tendon thickness were debrided and acromioplasty performed without repair.
Subscapularis Tear Repair
A full-thickness [/ partial-thickness upper third] subscapularis tear was identified. The subscapularis tendon was mobilized by releasing the comma sign tissue and coracohumeral ligament. The lesser tuberosity footprint was decorticated. [2] medial row anchors were placed, sutures passed through the subscapularis with a 45° suture passer, and tied. Subscapularis tears are frequently missed on MRI and require systematic evaluation at arthroscopy with the arm in external rotation and direct inspection of the biceps sheath and rotator interval.
Charting Tips
- Document tear size in two dimensions (AP and ML) using Cofield classification: small <1 cm, medium 1–3 cm, large 3–5 cm, massive >5 cm. Tear size drives repair technique selection and prognosis documentation.
- Document anchor number, size, and position (medial row vs. lateral row). Suture anchor purchase failure and re-tear are the most common complications. Record which configuration was used (single-row, double-row, or transosseous equivalent) and why.
- Document fatty infiltration and atrophy grade from pre-operative MRI using the Goutallier classification (Grade 0=normal, I=some fat, II=less than 50% fat, III=equal fat and muscle, IV=>50% fat). Grade III/IV predicts poor healing potential and justifies repair vs. debridement-only decision.
- For 29826 (acromioplasty) to survive audit, document all four elements: (1) subacromial space evaluation, (2) bursectomy performed, (3) acromioplasty with amount of bone resected, and (4) final acromion contour. Missing any element is grounds for denial.
- ICD-10: M75.100-M75.102 (unspecified rotator cuff tear, not specified as traumatic — right/left/unspecified), M75.110-M75.112 (incomplete/partial tear, not traumatic), M75.120-M75.122 (complete/full-thickness tear, not traumatic). For acute traumatic tears: S46.011A-S46.019A (strain), S46.021A-S46.029A (laceration), with 7th character A for initial encounter. The traumatic vs. non-traumatic distinction (S46 vs. M75) is clinically and billing-critical — document mechanism and chronicity.
Billing Tips
- Bill 29827 for arthroscopic rotator cuff repair (15.20 wRVU, 90-day global). This code applies regardless of tear size or number of anchors used.
- Open rotator cuff repair: 23410 (acute tear, 11.11 wRVU, 90-day global) or 23412 (chronic tear, 11.63 wRVU, 90-day global). Open codes carry lower wRVU than arthroscopic 29827. Ensure approach matches the code billed.
- Biceps tendon management — arthroscopic vs. open codes are NOT interchangeable: for arthroscopic procedures (29827), arthroscopic biceps tenodesis or tenotomy is coded 29828 (12.83 wRVU, 90-day global standalone primary code, separately reportable from 29827). For open repair procedures (23410/23412), biceps tenodesis = 23430 (9.92 wRVU) or tenotomy = 23405 (8.33 wRVU). Do not bill 23430/23405 alongside 29827 — those are open procedure codes only applicable with open repair codes.
- Subacromial decompression/acromioplasty (29826, 2.93 wRVU) is a true CPT add-on (ZZZ global) separately reportable with 29827. There is no current CMS NCCI edit bundling 29826 with 29827. AAOS Global Service Data Guide explicitly supports separate payment. To support 29826 billing, document all of: (1) evaluation of the subacromial space, (2) bursectomy performed, (3) acromioplasty with specific description of bone resected, and (4) final contour achieved. Without documentation of these four elements, 29826 is frequently denied on audit.
- 29823 (extensive arthroscopic debridement, 90-day global) is separately reportable with 29827 when documented extensive labral, synovial, or chondral debridement is performed — there is no current NCCI edit bundling 29823 with 29827. Document the extent of debridement, compartments involved, and specific tissues debrided to support 29823.
- 90-day global period: sling management, physical therapy initiation, and routine follow-up are bundled within the surgeon's global. PT sessions are billed independently by the therapist. Document the prescribed rehabilitation protocol in the discharge instructions.
General coding reference. Verify with your institution’s billing department before submitting claims.