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
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 RVU | 10.59 |
| Practice expense RVU | 9.57 |
| Malpractice RVU | 2.25 |
| Total RVU | 22.41 |
| Medicare national rate | $748.51 |
| Global period | 90 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
| Setting | Medicare 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?
02When is modifier 22 appropriate for 23155?
03Can 23155 be billed bilaterally?
04How does 23155 differ from related codes like 23150 or 23156?
05What imaging should be in the chart before billing 23155?
06Is a pathology report required to support 23155?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
- 01CMS Physician Fee Schedule 2026
- 02cms.govhttps://www.cms.gov/files/document/04-chapter4-ncci-medicare-policy-manual-2026-final.pdf
- 03cms.govhttps://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-faq-library
- 04findacode.comhttps://www.findacode.com/cpt/23155-cpt-code.html
- 05mdclarity.comhttps://www.mdclarity.com/cpt-code/23155
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