CPT 23412: Rotator cuff repair
What this code means, what it should cost, and how to dispute an overcharge.
Fair Price Reference
What is CPT 23412?
Rotator cuff repair — surgical repair of one or more torn tendons in the shoulder's rotator cuff. Can be done arthroscopically (small incisions) or open (larger incision). 90-day global surgical period includes all routine post-op visits.
Typical setting: Hospital outpatient or ambulatory surgery center.
What CPT 23412 should cost
The Centers for Medicare & Medicaid Services (CMS) pays approximately $1145 for CPT 23412 under the 2025 Physician Fee Schedule. This is what the federal government has determined is a reasonable payment for this service.
Private insurance typically pays 1.2–1.8x Medicare rates ($1374–$2061). Hospital chargemaster prices for CPT 23412 often range from $2500 to $12000 — a markup of 2.2x to 10.5x over Medicare.
Common overcharges on CPT 23412
Watch for post-operative visits billed separately during the 90-day global period. Also verify that only one approach (open vs. arthroscopic) is billed — some claims include both an arthroscopy code and an open repair code for the same shoulder.
About Orthopedics billing
Orthopedic procedures — joint surgeries, fracture repairs, spine operations, and arthroscopy — are among the highest-billed categories in medicine. Facility fees, implant markups, and bundled post-operative care create frequent billing disputes.
Request the operative report — it documents exactly what was performed. For arthroscopy, verify that diagnostic and therapeutic codes are not both billed. For fracture care, confirm only one treatment method (closed or open) is charged. Check that follow-up visits within the global period are not separately billed.
How to dispute a CPT 23412 overcharge
- Request the itemized bill. You are entitled to a detailed line-by-line bill showing every CPT code billed. Ask in writing.
- Compare to Medicare allowable. If the charge exceeds 150% of Medicare ($1718), you have grounds to dispute.
- Request documentation. For E&M codes, ask for the visit note. For procedures, ask for the operative report. The documentation must justify the code billed.
- Send a formal dispute letter. Cite the specific discrepancy between the documentation and the code. Reference Medicare rates and NCCI edits where applicable.
- Follow up in writing. Give the provider 30 days to respond. If they don't, escalate to the state attorney general and insurance commissioner.
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