Surgical removal of a tumor originating at or involving the proximal humerus, requiring radical resection of bone and surrounding tissue.
Verified May 8, 2026 · 5 sources ↓
- Medicare
- $1,737.51
- Total RVUs
- 52.02
- 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 ↓
- Pathologic diagnosis or strong clinical suspicion documented in the pre-op note, with tissue confirmation (biopsy report or intraoperative pathology) in the record
- Operative note must specify 'radical resection' with explicit description of margins, tissue planes entered, and extent of bone removed — vague language like 'tumor excision' will not support 23220
- Imaging studies (MRI, CT, or PET) documenting tumor location, size, and proximal humerus involvement must be present in the record
- If reconstruction was performed in the same session, a separate operative description of the reconstructive work is required to support additional codes
- Surgeon's attestation that resection was extracompartmental or wide-margin, consistent with oncologic radical resection standards
- For modifier 22: detailed narrative explaining the specific factors that increased complexity beyond the typical radical resection, with operative time and any unusual findings documented
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 23220 describes radical resection of a tumor of the proximal humerus — an aggressive oncologic procedure that goes beyond simple excision to include wide margins of bone, periosteum, and soft tissue. This is not a curettage or marginal excision; radical resection implies removal of the entire compartment or at minimum an extracompartmental resection to achieve oncologic control. The procedure is performed for primary bone tumors (osteosarcoma, chondrosarcoma) and occasionally aggressive metastatic disease when limb salvage is the goal.
With a 90-day global period and a high total RVU, this code reflects substantial intraoperative complexity and an extended postoperative management burden. Reconstruction after radical proximal humerus resection — whether with a prosthetic implant, allograft, or allograft-prosthesis composite — is coded separately. Coders must distinguish between the resection itself (23220) and any reconstruction that follows, and ensure operative notes support the radical nature of the resection rather than a more limited excision.
RVU & reimbursement
Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.
Source · CMS Physician Fee Schedule, RVU26A · January 2026
| Work RVU | 29.45 |
| Practice expense RVU | 16.31 |
| Malpractice RVU | 6.26 |
| Total RVU | 52.02 |
| Medicare national rate | $1,737.51 |
| 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 | $1,737.51 |
HOPD (APC 5114) Hospital outpatient department | $7,413.38 |
ASC (PI G2) Ambulatory surgical center (freestanding) | $3,695.53 |
Common denial reasons
The recurring reasons claims for CPT 23220 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- Operative note describes 'excision' or 'removal' without the language or detail needed to support radical resection — payers downcode to a lesser shoulder tumor excision code
- Missing pre-operative imaging or pathology report in the submitted record, triggering medical necessity denial
- Reconstruction CPT codes billed without a clearly separate operative description, causing bundling denials or edit conflicts
- E&M service billed same-day without modifier 25, denied as bundled into the 90-day global of a prior shoulder procedure or the surgical decision visit
- Lack of laterality modifier (LT or RT) causes claim rejection at facilities or payers requiring site specification for unilateral shoulder procedures
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 5 cited references ↓
01How does 23220 differ from other shoulder tumor excision codes?
02Can reconstruction be billed with 23220?
03What modifier applies when two attending surgeons co-operate on this resection?
04Is modifier LT or RT required for 23220?
05What global period applies and what does it cover?
06When is modifier 22 justified for 23220?
07Does a pre-operative E&M on the day of surgery get paid separately?
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/files/document/2026-ncci-medicare-policy-manual-all-chapters.pdf
- 04cgsmedicare.comhttps://www.cgsmedicare.com/medicare_dynamic/j15/partb/ptpb/ptp.aspx
- 05mdclarity.comhttps://www.mdclarity.com/cpt-code/23220
Mira AI Scribe
Mira's AI scribe captures the surgical approach, tumor compartment involvement, margin description, extent of proximal humeral bone resected, and whether neurovascular structures were encountered or sacrificed — the specific language auditors look for to distinguish radical resection from a lesser excision. This prevents downcoding to a non-radical shoulder tumor code and supports modifier 22 if complexity warrants it.
See how Mira captures CPT 23220 documentation