Soft tissue repair · Shoulder

23155

Surgical excision or curettage of a bone cyst or benign tumor located in the proximal humerus, involving removal of the lesion from the upper arm bone.

Verified May 8, 2026 · 5 sources ↓

Medicare
$748.51
Total RVUs
22.41
Global, days
90
Region
Shoulder
Drawn from CMSFindacodeMdclarity

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 5 cited references ↓

  • Lesion location specified as proximal humerus with anatomic detail (e.g., humeral head, surgical neck, greater tuberosity)
  • Lesion type documented — bone cyst (unicameral, aneurysmal) or benign tumor (e.g., enchondroma, osteochondroma) with dimensions
  • Operative note must state open approach explicitly; do not use 'standard approach' language without specifying the surgical technique
  • Pre-operative imaging (X-ray, MRI, or CT) in the record confirming lesion extent and location
  • Pathology report or intraoperative specimen description confirming benign nature of excised lesion
  • If modifier 22 is appended, dictation must quantify increased complexity — e.g., extensive cortical involvement, prior failed treatment, or unusual anatomic distortion

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

What this code covers

Source · Editorial summary grounded in 5 cited references ↓

CPT 23155 covers open surgical removal — by excision or curettage — of a bone cyst or benign tumor arising from the proximal humerus. The procedure is performed through an open approach, distinguishing it from arthroscopic or percutaneous techniques. Common pathology includes unicameral bone cysts, aneurysmal bone cysts, enchondromas, and other benign osseous lesions of the proximal humerus.

The 90-day global period means all routine postoperative care through day 90 is bundled into the payment — follow-up visits, wound checks, and suture removal. Any service unrelated to the index procedure billed during the global window requires modifier 24 (E/M) or modifier 79 (unrelated surgical procedure). A planned staged procedure in the postoperative period uses modifier 58; an unplanned return to the OR for a related complication uses modifier 78.

Bilateral presentation is rare but possible. If both humeri are addressed in the same session, append modifier 50. Document each lesion separately — size, location within the proximal humerus, and histopathologic characteristics — to support medical necessity and defend against downcoding audits.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU10.59
Practice expense RVU9.57
Malpractice RVU2.25
Total RVU22.41
Medicare national rate$748.51
Global period90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

SettingMedicare rate (national)
Office (PFS non-facility)
Procedure performed in physician's office
$748.51
HOPD (APC 5114)
Hospital outpatient department
$7,413.38
ASC (PI A2)
Ambulatory surgical center (freestanding)
$3,695.53

Common denial reasons

The recurring reasons claims for CPT 23155 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

  • Missing or inadequate pre-operative imaging documentation to support medical necessity for open excision
  • Operative note lacks specificity on lesion location and surgical approach, triggering a request for additional documentation
  • Procedure billed during the global period of a prior shoulder surgery without modifier 79 or 58 to distinguish timing and relationship
  • Modifier 22 appended without adequate narrative in the operative note quantifying the increased work performed
  • Bilateral billing (modifier 50) without separate documentation of distinct lesions in each humerus

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01Does 23155 have a global period, and what does that include?
23155 carries a 90-day global period. That covers the surgery, the day-before visit, and all routine postoperative care through day 90 — wound checks, dressing changes, suture removal. Bill unrelated services with modifier 24 (E/M) or modifier 79 (surgery). A staged procedure uses modifier 58. An unplanned return for a related complication uses modifier 78.
02When is modifier 22 appropriate for 23155?
Append modifier 22 when documented circumstances required substantially more work than the typical case — for example, a large lesion with extensive cortical destruction, prior curettage with recurrence, or complex anatomy from prior trauma. The operative note must describe the specific factors driving increased time and effort; modifier 22 without that narrative will be denied or ignored by most payers.
03Can 23155 be billed bilaterally?
Yes, but only when distinct lesions are treated in both humeri during the same operative session. Append modifier 50 for bilateral billing, and document each lesion separately in the operative note. Bilateral proximal humerus lesions are uncommon enough that payers may request records — have the imaging and pathology ready.
04How does 23155 differ from related codes like 23150 or 23156?
23150 covers excision or curettage of a bone cyst or benign tumor from the proximal humerus without bone grafting. 23155 is used when the procedure is performed with allograft or autograft bone grafting. 23156 is used when internal fixation is also performed. Select the code that matches the full extent of work documented in the operative report.
05What imaging should be in the chart before billing 23155?
At minimum, plain radiographs confirming the lesion. MRI or CT is strongly preferred for larger or complex lesions and is often required by payers to establish the benign nature and extent of the lesion pre-operatively. Missing imaging is a leading reason for medical necessity denials on this code.
06Is a pathology report required to support 23155?
Not always required by payer policy, but it is standard of care and critical for audit defense. The pathology report confirming a benign osseous lesion closes the loop on medical necessity and substantiates the procedure description. Without it, a post-payment audit can result in recoupment if the chart cannot confirm benign tumor or cyst.

Mira AI Scribe

Mira's AI scribe captures lesion location (proximal humerus, with sub-site detail), surgical approach, lesion type and dimensions, and any complexity factors from dictation — all in structured fields. That prevents the most common audit flag for 23155: an operative note that names the procedure but lacks the anatomic and pathologic specificity reviewers need to confirm the code. If you dictate increased difficulty, the scribe flags it for modifier 22 review before the claim goes out.

See how Mira captures CPT 23155 documentation

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