CPT 23420Surgery

Repair of shoulder

CPT 23420 covers surgical repair of the shoulder joint, typically involving reconstruction of damaged ligaments, tendons, or capsular structures to restore shoulder stability and function.

Showing rates for

National Average

Base Medicare rate

$964.25

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

13.54

PE RVU (NF)

13.52

MP RVU

2.75

Total RVU

29.81

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Always append laterality modifier (LT or RT) as CPT 23420 requires anatomic specification; claims will auto-deny without this modifier
Impact: Prevents automatic denial and 20-30 day payment delay; ensures clean claim submission
Document whether procedure is primary repair or revision surgery; revision cases may justify modifier 22 for increased complexity
Impact: Modifier 22 can increase reimbursement by $192.85-$385.70 when extensively documented with comparison to standard procedure
Verify global period (90 days) before billing any postoperative visits or related procedures; use modifier 79 for unrelated procedures during global
Impact: Prevents bundling denials; ensures separate payment for distinct procedures valued at full $964.25
Do not unbundle arthroscopic procedures if converted to open; bill only 23420 when starting arthroscopically but converting to open approach
Impact: Avoids $300-600 in denied arthroscopy codes (29806-29828) that are bundled into open repair
Separate billing for concomitant rotator cuff repair using appropriate codes (23410, 23412); ensure documentation supports distinct procedures
Impact: Additional $500-900 reimbursement when cuff repair is documented as separate pathology requiring additional work
For ASC settings, confirm 23420 is on facility's approved procedure list; some payers restrict to hospital outpatient only for complex shoulder repairs
Impact: Prevents facility claim denial; Medicare pays same $964.25 rate in both settings but some commercial payers differ

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23420 in 2025?

The 2025 Medicare national average payment for CPT 23420 is $964.25 for both facility and non-facility settings. This rate is based on 29.81 total RVUs multiplied by the 2025 conversion factor of $32.3465.

How many RVUs is CPT code 23420 worth?

CPT 23420 has 29.81 total RVUs in 2025, consisting of 13.54 work RVUs, 13.52 practice expense RVUs (both facility and non-facility), and 2.75 malpractice RVUs. This represents a moderately complex surgical procedure.

Can CPT 23420 be billed with arthroscopic shoulder codes?

No, CPT 23420 should not be billed with arthroscopic shoulder repair codes (29806-29828) for the same shoulder during the same operative session. If a procedure is converted from arthroscopic to open, bill only the open code 23420. Billing both creates unbundling issues and will result in denial.

Is a laterality modifier required for CPT 23420?

Yes, CPT 23420 absolutely requires a laterality modifier (LT for left shoulder or RT for right shoulder). Claims submitted without the appropriate modifier will be automatically denied by Medicare and most commercial payers. This is a mandatory billing requirement.

What is the global period for CPT 23420?

CPT 23420 has a 90-day global surgical period. This means routine postoperative care for 90 days after surgery is included in the reimbursement and cannot be billed separately. Any unrelated procedures during this period require modifier 79 for separate payment.

Can you bill CPT 23420 for arthroscopic shoulder repair?

No, CPT 23420 is specifically for open shoulder repair procedures requiring an incision for direct visualization. Arthroscopic shoulder repairs use different codes in the 29806-29828 range. Using 23420 for an arthroscopic procedure is incorrect coding and constitutes improper billing.

What documentation is needed to support medical necessity for CPT 23420?

Documentation must include diagnosis of shoulder instability or injury, imaging results (MRI or CT showing structural damage), evidence of conservative treatment failure (typically 3-6 months of physical therapy), functional limitations, recurrent dislocation history if applicable, and clear justification for open surgical approach rather than arthroscopic technique.