CPT 23430Surgery

Repair biceps tendon

CPT code 23430 covers surgical repair of a torn or damaged biceps tendon in the shoulder area. This is a common procedure for athletes and active individuals who experience biceps tendon rupture or chronic tendon deterioration.

Showing rates for

National Average

Base Medicare rate

$737.18

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

10.17

PE RVU (NF)

10.64

MP RVU

1.98

Total RVU

22.79

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 this is mandatory for shoulder procedures
Impact: Prevents automatic denial and claim reprocessing delays of 15-30 days
When performed with rotator cuff repair (29827), bill 23430 with modifier 51 as it has lower RVUs than most arthroscopic rotator cuff codes
Impact: Proper sequencing maximizes reimbursement; incorrect ordering can reduce total payment by $200-400
Document whether repair is for proximal long head or short head biceps tendon as this affects code selection and medical necessity
Impact: Prevents downcoding or denials for lack of specificity; ensures the $737.18 payment versus potential denial requiring appeal
Verify if arthroscopic biceps tenodesis (29828) is more appropriate; 23430 is for open repair while 29828 is arthroscopic approach
Impact: Code selection error can result in complete denial; 29828 reimburses differently and has different facility/non-facility rates
For Medicare patients, ensure diagnosis codes support medical necessity (M24.81, M75.2, S46.11) and document failed conservative treatment
Impact: LCD non-compliance results in denials; proper documentation supports $737.18 payment versus $0 for denied claims
When biceps tendon repair is performed during total shoulder arthroplasty, consider bundling implications as some payers include this in global surgical package
Impact: Unbundling can trigger audits and recoupment; verify payer policy to avoid potential $737.18 overpayment recovery

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23430 in 2025?

The 2025 Medicare national average reimbursement for CPT 23430 is $737.18 for both facility and non-facility settings. This rate is based on 22.79 total RVUs multiplied by the 2025 conversion factor of 32.3465. Actual reimbursement may vary based on geographic location and MAC-specific pricing.

What is the difference between CPT 23430 and 29828?

CPT 23430 describes an open surgical repair of the biceps tendon, while CPT 29828 describes arthroscopic biceps tenodesis. The key difference is the surgical approach: 23430 requires an open incision for direct access to the tendon, whereas 29828 is performed through small arthroscopic portals using a camera and instruments. Code selection must match the documented surgical approach.

Can CPT 23430 be billed with a rotator cuff repair code?

Yes, CPT 23430 can be billed with rotator cuff repair codes when both procedures are medically necessary and documented separately. However, you must append modifier 51 to the lower-valued procedure (typically 23430) and verify NCCI edits. Some payers may consider biceps tendon work incidental to rotator cuff repair and deny separate payment.

What modifiers are required when billing CPT 23430?

Laterality modifiers LT (left) or RT (right) are mandatory when billing CPT 23430. Additional modifiers may include 51 (multiple procedures), 22 (increased procedural services), 78 (return to OR), or 80 (assistant surgeon) depending on the specific case circumstances. Missing laterality modifiers will result in automatic claim denial.

How many RVUs is CPT code 23430 worth in 2025?

CPT 23430 has a total of 22.79 RVUs in 2025, broken down as: 10.17 work RVUs, 10.64 practice expense RVUs (both facility and non-facility), and 1.98 malpractice RVUs. These values are from the CMS Physician Fee Schedule RVU25A released December 23, 2024.

What diagnosis codes support medical necessity for CPT 23430?

Common supporting diagnosis codes include S46.111A-S46.119A (strain of long head of biceps), M24.812 (shoulder disorder following biceps tendon rupture), M75.20-M75.22 (bicipital tendinitis), and M66.211-M66.212 (spontaneous rupture of biceps tendon). Documentation must show correlation between diagnosis and surgical intervention with evidence of failed conservative treatment.

Is CPT 23430 performed as an inpatient or outpatient procedure?

CPT 23430 is typically performed as an outpatient procedure in either a hospital outpatient department or ambulatory surgery center. The facility and non-facility Medicare rates are identical at $737.18, indicating no expected difference in site of service. Inpatient admission for isolated biceps tendon repair would be extremely rare and require exceptional medical justification.