Open treatment of a proximal humeral fracture involving the surgical or anatomical neck, with or without internal fixation, tuberosity repair, and/or humeral head prosthetic replacement.

Verified May 8, 2026 · 6 sources ↓

Medicare: $1,121.60
Total RVUs: 33.58
Global, days: 90
Region: Shoulder

Drawn from CMSAAPCFastrvuCgsmedicare

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Fracture classification and anatomic location — specify surgical neck, anatomical neck, or proximal humeral neck with part description (two-part, three-part, four-part)
Operative note must name the specific fixation method used (locked plate, pins, screws, prosthesis, or combination) — 'standard fixation' is insufficient for audit review
Explicit documentation of tuberosity involvement and whether repair was performed, including attachment technique if prosthesis placed
Indication for open versus closed treatment — document why closed reduction was not attempted or was inadequate
Implant manufacturer, model, and lot number when a prosthetic humeral head is placed, per facility and payer implant reporting requirements
Pre-operative imaging (X-ray, CT) confirming fracture pattern to support code-level selection and medical necessity

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 25 Significant separate E/M 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 57 Decision for surgery 58 Staged or related 59 Distinct service 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 23616 covers open surgical management of proximal humeral fractures — specifically surgical or anatomical neck fractures — that require direct fracture exposure. The surgeon may apply internal fixation (plates, screws, pins), repair the greater and/or lesser tuberosities, perform a humeral head hemiarthroplasty, or combine these elements depending on fracture pattern and bone quality. The code encompasses all components performed at the same operative encounter, including tuberosity reattachment to the prosthesis when a hemiarthroplasty is used for fracture reconstruction.

This is the correct code for fracture hemiarthroplasty of the proximal humerus. Do not confuse it with 23470 (hemiarthroplasty for non-fracture indications such as arthritis) or 23472 (total shoulder arthroplasty). If the operative note documents humeral head replacement with tuberosity repair in the setting of an acute fracture, 23616 is the code — not 23470. The global period is 90 days, covering the surgery date, the day-before visit, and all routine post-operative care through day 90.

Site of service matters here. HOPD and ASC payment rates differ substantially. Confirm facility credentials and place-of-service codes before submitting. For bilateral proximal humeral fractures treated at the same session — rare but possible — report with modifier 50 on a physician claim; ASC facilities use separate LT and RT lines per NCCI Chapter 4 guidance.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	17.91
Practice expense RVU	11.97
Malpractice RVU	3.7
Total RVU	33.58
Medicare national rate	$1,121.60
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	$1,121.60
HOPD (APC 5116) Hospital outpatient department	$17,913.59
ASC (PI J8) Ambulatory surgical center (freestanding)	$13,437.31

Common denial reasons

The recurring reasons claims for CPT 23616 get rejected.

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

Wrong code selected: 23470 billed instead of 23616 when operative note clearly documents fracture as the indication for hemiarthroplasty
Missing fracture diagnosis: ICD-10 fracture code absent or mismatched — claim submitted with degenerative or dislocation diagnosis rather than acute fracture
Global period conflict: post-op visits billed without modifier 24 when an unrelated E/M is provided during the 90-day global window
Unbundling: separately billing tuberosity repair codes when the repair is integral to and included in 23616
Medical necessity not established: operative note lacks documentation of failed or inappropriate conservative management prior to open fixation

Frequently asked questions

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

01When should I use 23616 versus 23470?

23616 is for fracture — the humeral head replacement or fixation is performed because of an acute proximal humeral fracture. 23470 is for non-fracture hemiarthroplasty, typically avascular necrosis or arthritis. The operative indication in the note drives the choice. If the op note says 'comminuted proximal humeral fracture' and a prosthesis was placed, bill 23616.

02Is tuberosity repair separately billable when performed with 23616?

No. Tuberosity repair is included in 23616 when performed at the same operative encounter. The code descriptor explicitly covers internal fixation and tuberosity repair as components. Billing a separate repair code will trigger an NCCI bundling denial.

03What modifiers apply when 23616 is performed on both shoulders at the same session?

Physician claims: use modifier 50 on a single line. ASC claims: report two lines, one with modifier LT and one with modifier RT, each with one unit of service, per NCCI Chapter 4 bilateral surgical procedure reporting rules.

04Can I bill an E/M visit on the day of surgery for a separate problem?

Yes, with modifier 25 on the E/M if the visit is for a significant, separately identifiable problem unrelated to the fracture. For E/M visits during the 90-day global period for unrelated problems, use modifier 24. Document clearly that the visit was not part of routine fracture post-op management.

05What is the global period for 23616 and what does it include?

23616 carries a 90-day global period. It includes the day-before pre-op visit, the surgery itself, and all routine post-operative management through day 90 — wound checks, suture removal, standard dressing changes, and fracture healing follow-up. Services unrelated to the shoulder fracture require modifier 24 or 79 depending on whether a new procedure is involved.

06Does 23616 include fluoroscopy used intraoperatively?

Yes. Per NCCI policy, fluoroscopy used during a surgical procedure is integral to and not separately reportable from the primary procedure. Do not add a fluoroscopy code to 23616 for intraoperative imaging guidance.

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 fracture classification, anatomic site (surgical vs. anatomical neck), fixation method by name, tuberosity repair details, and implant specifics from the surgeon's dictation. For fracture hemiarthroplasty cases, it flags when humeral head replacement language appears alongside tuberosity repair, prompting 23616 instead of 23470 — the single most common miscoding pattern auditors flag for this procedure family.

See how Mira captures CPT 23616 documentation