Open surgical treatment of a proximal humeral fracture at the surgical or anatomical neck, with internal fixation and tuberosity repair when performed.

Verified May 8, 2026 · 8 sources ↓

Medicare: $823.67
Total RVUs: 24.66
Global, days: 90
Region: Shoulder

Drawn from CMSAAPCFindacodeAbosJnjmedtech

Documentation requirements

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

Source · Editorial brief grounded in 8 cited references ↓

Fracture type and location: specify surgical neck vs. anatomical neck, displacement, and comminution pattern
Operative note must name the surgical approach used (e.g., deltopectoral, anterolateral) — not 'standard approach'
Explicit documentation of internal fixation method (plate and screw construct, IM nail, tension band, etc.) if fixation was performed
Documentation of tuberosity involvement and repair technique if tuberosity repair was performed
Pre-op imaging (X-ray, CT) in the record confirming fracture characteristics that necessitated open treatment
Neurovascular status documented pre- and post-operatively
Laterality clearly stated in the operative note and on the claim (LT or RT modifier)

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 51 Multiple procedures 52 Reduced services 58 Staged or related 59 Distinct service 62 Co-surgeons 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 8 cited references ↓

23615 covers open reduction of proximal humeral fractures at the surgical or anatomical neck. The code includes internal fixation and tuberosity repair when those steps are performed — no separate code is needed for either component. This is the go-to code when closed treatment (23605) fails or when fracture displacement, comminution, or neurovascular compromise demands direct surgical exposure.

The 90-day global period covers the day-before visit, the surgery itself, and all routine post-op care through day 90. Anything unrelated to the fracture billed in that window requires modifier 24 (E/M) or 79 (unrelated procedure). If the patient returns for a planned staged procedure — say, conversion to arthroplasty — append modifier 58, which resets the global clock. An unplanned return to the OR for a related complication gets modifier 78 instead.

CCI bundles 23615 into 23472 (total shoulder arthroplasty for fracture) when both are reported in the same encounter — bill the more comprehensive code only. Similarly, 23430 (biceps tenodesis) is bundled as a component when 23472 is the primary procedure. Cigna has also flagged 29806 as bundled with 23615 at the claim level, though NCCI edits do not support that; appeal with operative note documentation showing distinct procedural services.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	11.99
Practice expense RVU	10.18
Malpractice RVU	2.49
Total RVU	24.66
Medicare national rate	$823.67
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	$823.67
HOPD (APC 5115) Hospital outpatient department	$13,116.76
ASC (PI J8) Ambulatory surgical center (freestanding)	$9,193.89

Common denial reasons

The recurring reasons claims for CPT 23615 get rejected.

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

Missing or wrong laterality modifier — LT/RT required; claim drops without one at many payers
Payer bundles 23615 into 23472 when total shoulder arthroplasty is billed same session — only the more comprehensive code survives
Cigna-specific bundling denial pairing 23615 with 29806, which NCCI edits do not support; requires appeal with operative note
Modifier 22 attached without supporting documentation quantifying the increased work — auditors reject vague operative note language
Global period violation: post-op E/M billed within 90 days without modifier 24, triggering bundling denial

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 8 cited references ↓

01Does 23615 include internal fixation, or do I bill that separately?

Internal fixation is included in 23615 when performed. Don't add a separate fixation code — it's already bundled into the procedure.

02Which code do I use for intramedullary nailing of a proximal humerus fracture?

This is genuinely contested. Many coders bill 23615 for IM nailing of proximal humerus fractures because no dedicated code exists for that construct at this location. Document the implant and technique specifically; some payers scrutinize this. Check your MAC's guidance before submitting.

03Can I bill 23615 and 23472 together when the surgeon converts a fracture to total shoulder arthroplasty in the same session?

No. CCI bundles 23615 into 23472. Bill 23472 as the primary code — it is the more comprehensive procedure and captures the entire encounter.

04How do I bill a second surgery during the 90-day global if the patient needs conversion to arthroplasty?

Use modifier 58 for a planned staged procedure. It resets the global period. If the return to the OR was unplanned and related to a complication, use modifier 78 instead — and do not invert these two.

05Cigna denied 23615 bundled with 29806. Is that correct?

NCCI edits do not bundle 23615 with 29806. This is a Cigna-specific claim-level denial. Appeal with the operative note showing distinct surgical sites and separate indications for each procedure.

06When is modifier 22 justified for 23615?

Use modifier 22 when documented circumstances substantially increase physician work — severe comminution requiring extended fixation time, prior hardware removal, morbid obesity, or prior failed fixation. The operative note must quantify the additional time and technical difficulty. Generic language like 'complex fracture' will not hold up on audit.

07Does 23615 cover tuberosity repair, or is that a separate billable service?

Tuberosity repair is included in 23615 when performed. It is not separately billable in the same session under this code.

Sources & references

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

Mira AI Scribe

Mira's AI scribe captures fracture location (surgical vs. anatomical neck), displacement and comminution details, surgical approach by name, fixation construct used, tuberosity involvement and repair technique, and laterality — directly from dictation. That documentation set satisfies the primary audit triggers for 23615: approach specificity, fixation confirmation, and tuberosity repair status. Missing any of these is the fastest path to a modifier 22 rejection or a medical necessity denial.

See how Mira captures CPT 23615 documentation