Open removal of a bone lesion from the shaft or head of the humerus, including any necessary bone grafting to fill the resulting defect.

Verified May 8, 2026 · 6 sources ↓

Medicare: $642.63
Work RVU: 8.88
Global, days: 90
Region: Shoulder

Drawn from CMSCgsmedicareAAOS

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Lesion location on the humerus — head, neck, shaft, or distal segment — documented by name in the operative report
Confirmation that bone grafting was performed, including graft type (autograft, allograft, synthetic) and source site if autograft
Preoperative imaging (X-ray, MRI, or CT) identifying the lesion and supporting surgical indication
Pathology report or intraoperative specimen description linking the lesion to the operative diagnosis
Diagnosis code (ICD-10) specifying whether the lesion is benign, aggressive/locally destructive, or neoplastic — medical necessity hinges on this distinction
Operative note documenting the approach, extent of resection, and method of defect reconstruction

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 58 Staged or related 59 Distinct service 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 23156 covers open excision of a benign or aggressive lesion from the humerus when the procedure requires bone grafting to reconstruct the defect left after tumor removal. This distinguishes it from 23155, which is the same excision without grafting. The graft can be autograft or allograft; the use of grafting material is what drives the code selection, not graft source.

The 90-day global period means all routine post-op visits, wound checks, and graft-site management are bundled through day 90. Any visit for a problem unrelated to the humeral lesion excision needs modifier 24. A return to the OR for a complication directly related to this procedure — infection, graft failure — gets modifier 78.

Site of service matters here. HOPD and ASC payments differ substantially; see the Site of Service comparison table. Bilateral humeral lesion cases are exceedingly rare, but if performed, modifier 50 applies. Document the lesion location precisely (head, neck, shaft, distal humerus), the graft type and source, and the pathologic indication — these are the details that drive both correct code selection and medical necessity.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (8.88) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (19.24) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	8.88
Practice expense RVU	8.46
Malpractice RVU	1.9
Total RVU	19.24
Medicare national rate	$642.63
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	$642.63
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 23156 get rejected.

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

Upcoding flag when bone grafting is not documented — payers downcode to 23155 if the graft isn't confirmed in the operative note
Medical necessity denial when preoperative imaging or pathology report is absent from the record
Global period conflict — post-op E/M or office visit billed without modifier 24 for an unrelated condition
Incorrect site-of-service billing when the procedure is performed in an ASC but billed under HOPD facility rates
Unbundling denial when graft harvest (e.g., iliac crest) is separately billed without supporting documentation of a distinct operative site

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01What is the difference between 23155 and 23156?

23155 is humeral lesion excision without bone grafting. 23156 requires that bone grafting be performed to fill the surgical defect. Graft type — autograft, allograft, or synthetic — doesn't change the code, but the act of grafting must be documented to support 23156 over 23155.

02Can I separately bill for autograft harvest when reporting 23156?

Only if the harvest site is a distinctly separate surgical site and that work is documented as such. Use modifier XS or 59 to indicate a separate anatomic location. Without that documentation, the harvest is considered bundled.

03What modifier applies if the patient returns to the OR for graft failure within the 90-day global?

Modifier 78 — unplanned return to the OR for a procedure related to the original surgery during the global period. Graft failure is directly related to 23156, so 78 is correct. Do not use modifier 79, which is reserved for unrelated procedures.

04Does the 90-day global include management of the donor graft site?

Yes, if the donor site management is routine post-operative care. If the donor site develops a complication requiring a separately identifiable service — wound dehiscence, infection requiring I&D — document it thoroughly and append modifier 24 to the E/M or the appropriate procedure code.

05Which diagnosis codes support medical necessity for 23156?

Benign bone tumors (ICD-10 D16.0 for humerus), aggressive or locally destructive lesions, giant cell tumors, and other primary bone neoplasms of the humerus are the typical supporting diagnoses. Metastatic disease coding may apply in select cases. The pathology report should align with the ICD-10 submitted.

06Is modifier 22 ever appropriate for this code?

Yes, when the lesion excision is substantially more complex than typical — for example, a large destructive lesion requiring extensive cortical reconstruction or unusual graft technique. Document increased operative time, complexity, and the specific factors that made the case an outlier. Payers expect a compelling narrative, not just a time log.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the lesion's anatomic location on the humerus, the surgeon's confirmation that bone grafting was performed, graft type and harvest site, and the extent of resection from dictation. That prevents the most common denial for this code: a payer downcode to 23155 because the operative note failed to explicitly document the grafting step.

See how Mira captures CPT 23156 documentation