Surgical removal of the humeral head — the ball-shaped proximal end of the humerus — typically performed for osteomyelitis, avascular necrosis, tumor, or severe trauma that makes joint preservation or replacement unfeasible.

Verified May 8, 2026 · 6 sources ↓

Medicare: $709.77
Total RVUs: 21.25
Global, days: 90
Region: Shoulder

Drawn from CMSAAPCMdclarityAuthorizationsVa

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Preoperative diagnosis with ICD-10 code that directly supports humeral head resection (e.g., osteomyelitis, AVN, neoplasm, pathologic fracture)
Operative note naming the surgical approach (deltopectoral, transdeltoid) — do not write 'standard approach'
Explicit documentation that prosthetic reconstruction (hemiarthroplasty or total shoulder) was not feasible and the clinical rationale why
Intraoperative findings describing the extent and condition of humeral head pathology removed
Laterality clearly stated in both the operative note and on the claim (LT or RT modifier)
If antibiotic spacer placed, document separately with intent, spacer type, and whether it is temporary or permanent

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 50 Bilateral procedure 51 Multiple procedures 59 Distinct service 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 23195 covers complete resection of the humeral head at the glenohumeral joint. It is used when the proximal humerus is destroyed by infection (osteomyelitis), necrosis, malignancy, or catastrophic fracture and the bone cannot support a prosthetic implant or conventional arthroplasty. The result is a resection arthroplasty — a 'flail shoulder' construct — that trades stability for pain relief and preserved soft-tissue function.

The 90-day global period applies. All routine post-op visits, wound care, and rehabilitation management within that window are bundled. Anything unrelated to the shoulder resection billed in the same window needs modifier 24 (E/M) or 79 (unrelated procedure). If the surgeon places an antibiotic spacer during the same session — common in infected cases — document that work separately and evaluate whether an additional code is supported; payers vary on spacer placement billing alongside 23195.

Prior authorization is required by many commercial payers, including BCBS of Michigan plans. Secure auth before scheduling. ICD-10 diagnosis alignment is a top denial trigger: osteomyelitis, pathologic fracture, or neoplasm codes must match operative findings documented in the note. Audit teams will also scrutinize whether hemiarthroplasty (23470) would have been more appropriate — the operative note must clearly explain why prosthetic reconstruction was not performed.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	10.1
Practice expense RVU	9
Malpractice RVU	2.15
Total RVU	21.25
Medicare national rate	$709.77
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	$709.77
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI J8) Ambulatory surgical center (freestanding)	$4,682.29

Common denial reasons

The recurring reasons claims for CPT 23195 get rejected.

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

ICD-10 diagnosis code does not support medical necessity for full humeral head resection versus less aggressive treatment
Payer determines hemiarthroplasty (23470) was the appropriate code based on operative note language describing implant preparation
Missing or expired prior authorization — required by most commercial and Medicare Advantage plans for this level of shoulder surgery
Laterality modifier (LT/RT) absent, triggering automated claim rejection
Global period conflict: post-op E/M billed without modifier 24, or related return-to-OR billed without modifier 78

Frequently asked questions

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

01When does 23195 apply instead of hemiarthroplasty (23470)?

Use 23195 when the humeral head is removed without placement of a prosthetic implant. If the surgeon implants a humeral component — even temporarily — 23470 or a spacer-specific code is more appropriate. The operative note must explicitly state why implant placement was not performed.

02Can 23195 and antibiotic spacer placement be billed together?

Payer policies vary. Some accept a separate code for spacer placement alongside 23195; others bundle it. Document the spacer work thoroughly and check individual payer NCCI edits. Medicare does not have a clean standalone spacer code for this anatomic site — submit with modifier 59 or XS if billing separately and expect pre-payment review.

03Does the 90-day global period apply to 23195?

Yes. The 90-day global covers the surgery, the day-before visit, and all routine post-op care through day 90. Bill unrelated E/M services with modifier 24 and unrelated procedures with modifier 79. A related unplanned return to the OR takes modifier 78.

04Is prior authorization required for 23195?

Yes, for most commercial payers and Medicare Advantage plans. BCBS of Michigan explicitly lists 23195 as requiring prior auth. Obtain authorization before scheduling and confirm the auth number is on the claim. Missing auth is a clean-claim requirement failure, not a clinical denial — it typically cannot be appealed on medical necessity grounds.

05What ICD-10 codes typically support 23195?

Osteomyelitis of the humerus (M86 series), avascular necrosis of the humeral head (M87 series), pathologic fracture due to neoplasm or infection, and primary or metastatic bone tumor codes (C40.0x, D16.0x) are the most commonly accepted. Degenerative arthritis alone rarely justifies resection over arthroplasty — expect scrutiny if an M19 code is the only diagnosis.

06Should modifier 50 be used if both shoulders are resected in the same session?

Yes. Bilateral same-session resection is exceedingly rare but if it occurs, append modifier 50 and expect the second side to be reimbursed at 50% of the allowed amount per Medicare multiple-procedure rules. Document the separate clinical indication for each side.

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 approach by name, the intraoperative findings describing humeral head pathology, the surgeon's stated rationale for resection over prosthetic reconstruction, and laterality — all from dictation. That documentation directly defends against the two most common audit flags for 23195: upcoding to hemiarthroplasty and insufficient medical necessity for bone removal over joint replacement.

See how Mira captures CPT 23195 documentation