Open surgical repair of a greater humeral tuberosity fracture, with or without internal or external fixation hardware such as screws or pins.

Verified May 8, 2026 · 7 sources ↓

Medicare: $734.15
Total RVUs: 21.98
Global, days: 90
Region: Shoulder

Drawn from CMSAAPCFacultyAAOS

Documentation requirements

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

Source · Editorial brief grounded in 7 cited references ↓

Operative note must name the specific fixation method used (e.g., cannulated screws, pins, suture anchors, or external fixation device) — 'internal fixation' alone is insufficient for audit defense.
Pre-op imaging (X-ray or CT) confirming displacement or failure of closed management, justifying the open approach.
ICD-10-CM fracture code with laterality (right/left) and displacement status documented in both the op note and the diagnosis list.
If a concurrent rotator cuff tear is repaired, a separate diagnosis code and a distinct operative description addressing the tear as a separate clinical finding must appear in the record.
Neurovascular status of the extremity documented pre- and intraoperatively, particularly axillary nerve assessment.
Implant log or device sticker in the operative record when screws, anchors, or plates are used.

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 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 LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

CPT 23630 covers open treatment of a greater humeral tuberosity fracture — the bony prominence at the top of the humerus where the supraspinatus, infraspinatus, and teres minor tendons attach. The surgeon opens the fracture site and reduces the fragment, then stabilizes it with internal fixation (screws, pins, suture anchors) or external fixation as the anatomy dictates. This is distinct from the closed treatment codes 23620 (without manipulation) and 23625 (with manipulation), which do not involve surgical opening.

The 90-day global period covers all routine post-op care through day 90. Any E/M visit during that window for an unrelated problem requires modifier 24; a significant, separately identifiable E/M on the day of surgery requires modifier 25. A concurrent rotator cuff repair (e.g., 23410 or 23412) is subject to NCCI procedure-to-procedure (PTP) edits — check current CMS PTP tables before billing both codes on the same claim, and append modifier 59 or an X-modifier only when a distinct, separately documented indication exists.

This code is billed primarily by orthopedic and hand surgeons. Site-of-service matters: HOPD and ASC payment rates differ substantially (see the Site of Service comparison table). The ICD-10-CM fracture code must specify laterality and displacement status to support medical necessity; a mismatch between the diagnosis and the open fixation approach is a common payer audit trigger.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	10.31
Practice expense RVU	9.56
Malpractice RVU	2.11
Total RVU	21.98
Medicare national rate	$734.15
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	$734.15
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI J8) Ambulatory surgical center (freestanding)	$4,730.99

Common denial reasons

The recurring reasons claims for CPT 23630 get rejected.

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

ICD-10-CM code lacking laterality or displacement specificity — payers reject unspecified fracture codes paired with an open fixation procedure.
Concurrent rotator cuff repair (23410/23412) billed on the same claim without modifier 59 and a separately documented rotator cuff tear diagnosis, triggering NCCI PTP bundling denial.
E/M visit billed on the same day as surgery without modifier 25, or post-op E/M billed within the 90-day global without modifier 24.
Lack of documentation supporting medical necessity for open treatment when closed treatment codes (23620/23625) may appear sufficient based on imaging submitted.
Assistant surgeon billed without supporting documentation that the procedure complexity required an assistant, or when payer policy restricts assistant surgeon payment for this code.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01Can I bill 23630 and a rotator cuff repair code (23410 or 23412) together?

These code pairs are subject to NCCI PTP edits. To bill both, you need a separately documented rotator cuff tear diagnosis distinct from the fracture, and modifier 59 appended. Verify the current edit status in the CMS PTP tables before submitting — the edit status has changed across years and your MAC may differ.

02What's the difference between 23620, 23625, and 23630?

23620 is closed treatment without manipulation; 23625 is closed treatment with manipulation; 23630 is open treatment, meaning a surgical incision is made and the fracture is directly visualized and reduced. Only 23630 permits billing of internal or external fixation.

03What global period applies, and what does it include?

23630 carries a 90-day global period. That covers the day-before visit, the procedure itself, and all routine post-op care through day 90 — including dressing changes, suture removal, and routine follow-up imaging interpretation. Unrelated problems during this window need modifier 24 on the E/M.

04When is modifier 22 appropriate for 23630?

Use modifier 22 when the work is substantially greater than typical — for example, a highly comminuted fragment requiring complex reconstruction, significant scar tissue from a prior surgical attempt, or marked obesity requiring significantly extended operative time. The op note must describe in detail what made the case atypically difficult; without that narrative, payers will recoup the modifier.

05Does site of service affect reimbursement for 23630?

Yes, significantly. HOPD and ASC payment rates differ — see the Site of Service comparison on this page. Physician work RVUs are the same regardless of setting, but facility payment to the hospital or ASC varies, which affects your negotiating position and total episode cost.

06Which ICD-10-CM codes pair with 23630?

You need a fracture code from the S42.2x range specifying the greater tuberosity, with laterality (right: S42.251–S42.256; left: S42.261–S42.266) and displacement status. Unspecified laterality or displacement codes will flag for medical necessity review with an open fixation procedure.

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 fragment description, reduction technique, fixation hardware type and size, approach name, and any concurrent rotator cuff pathology addressed — all from the surgeon's dictation. This prevents the two most common audit flags: an operative note that names fixation without specifying implants, and a concurrent soft-tissue repair that lacks a separately documented diagnosis to support unbundling from 23630.

See how Mira captures CPT 23630 documentation