CPT 23065Surgery

Biopsy shoulder tissues

CPT 23065 covers a biopsy of shoulder tissues, where a small sample is taken from the shoulder area to check for abnormalities, infection, or disease. This is a diagnostic procedure typically performed when imaging or physical examination suggests a problem that needs tissue analysis.

Showing rates for

National Average

Base Medicare rate

$218.99

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

2.3

PE RVU (NF)

4.12

MP RVU

0.35

Total RVU

6.77

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Always specify facility vs non-facility setting accurately as reimbursement differs by $62.76 (29% variance) between settings
Impact: Incorrect place of service coding can result in automatic recoupment of $62.76 per claim during audits
Document the exact anatomical location and depth of biopsy (superficial vs deep tissue) as this affects code selection versus 20200-20206 series
Impact: Incorrect depth coding could result in downcoding to 20206 ($152.34) representing a $66.65 loss per claim
When performed with imaging guidance, bill separately for ultrasound (76942) or fluoroscopy (77002) as these are not bundled with 23065
Impact: Capturing imaging guidance adds $40-80 per procedure when medically necessary and documented
Verify the National Correct Coding Initiative (NCCI) edits before billing with arthroscopy codes on the same date; 23065 is typically separate from arthroscopic procedures
Impact: Prevents automatic denials and need for appeals; can protect 20-30% of revenue on combination procedures
Submit pathology report with initial claim when billing Medicare or requires prior authorization; demonstrates medical necessity and reduces denial rate
Impact: Reduces initial denial rate by approximately 40% and eliminates 2-4 week payment delays from appeals
Use modifier LT/RT consistently across all claims for the patient to prevent laterality confusion that triggers medical review
Impact: Prevents payment suspensions averaging 30-45 days while under medical review for laterality verification

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23065 in 2025?

The 2025 Medicare national average reimbursement is $218.99 for non-facility settings and $156.23 for facility settings. The difference reflects overhead costs assumed by the facility versus the physician practice. Actual payment may vary by geographic locality based on the GPCI adjustment.

How many RVUs is CPT code 23065 worth?

CPT 23065 has a total RVU value of 6.77, consisting of 2.3 work RVUs, 4.12 practice expense RVUs (non-facility), 2.18 practice expense RVUs (facility), and 0.35 malpractice RVUs. These values are from the CMS 2025 Medicare Physician Fee Schedule.

Can CPT 23065 be billed with an office visit on the same day?

Yes, but only when a significant, separately identifiable evaluation and management service is performed beyond the routine pre-procedure assessment. Append modifier 25 to the E/M code and ensure documentation clearly demonstrates the separate nature of the E/M service, such as evaluation of other conditions or comprehensive assessment that led to the biopsy decision.

What is the difference between CPT 23065 and 20206?

CPT 23065 is specific to shoulder tissue biopsy including muscles, tendons, and other shoulder-specific structures. CPT 20206 describes deep soft tissue biopsy without anatomical specificity. Use 23065 when the biopsy is performed specifically on shoulder anatomical structures; use 20206 for deep soft tissue biopsies in other locations or non-specific soft tissue masses.

Does CPT 23065 require prior authorization from insurance?

Prior authorization requirements vary by payer and plan. Medicare typically does not require prior authorization for 23065, but medical necessity must be documented. Many commercial payers and managed care plans do require prior authorization, especially when performed in ambulatory surgery centers. Always verify with the specific payer before scheduling the procedure.

Can you bill for imaging guidance separately with CPT 23065?

Yes, imaging guidance codes such as 76942 (ultrasound guidance) or 77002 (fluoroscopic guidance) are not bundled with 23065 and can be billed separately when the imaging is used to guide needle placement during the biopsy. Documentation must support the medical necessity and use of imaging guidance throughout the procedure.

What diagnosis codes are typically used with CPT 23065?

Common diagnosis codes include M79.9 (soft tissue disorder, unspecified), M25.511-M25.512 (shoulder pain), D48.1 (neoplasm of uncertain behavior of connective tissue), R22.31 (localized swelling of upper limb), and M75.xx codes for specific shoulder lesions. The diagnosis must support medical necessity for the biopsy, typically requiring abnormal imaging findings or unexplained clinical presentation.