CPT 23078Surgery

Resect shoulder tumor 5 cm/>

CPT code 23078 covers surgical removal of a shoulder tumor that measures 5 centimeters or larger in its deepest dimension. This is a complex procedure requiring open surgical technique to excise large masses from the soft tissues of the shoulder region.

Showing rates for

National Average

Base Medicare rate

$1,411.28

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

22.55

PE RVU (NF)

16.03

MP RVU

5.05

Total RVU

43.63

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

NCCI bundling edits

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Billing tips

Document tumor dimensions in three planes (length, width, depth) in operative report with specific measurement of deepest extent being 5 cm or greater
Impact: Prevents downcoding to 23075 ($705.64 difference in reimbursement); size documentation is the primary audit target for this code
Include pre-operative imaging reports (MRI or CT) showing tumor size in the medical record submitted with initial claim or prior authorization
Impact: Reduces denial rate by 60-70% for high-value tumor resection codes; establishes medical necessity and size threshold before surgery
Submit pathology report documenting specimen dimensions and tumor type within 30 days of procedure to insurers that require post-operative confirmation
Impact: Required for final payment by many commercial payers; failure to submit may result in recoupment or reduction to provisional payment rate
When billing with complex closure or flap codes (13XXX-14XXX), document that closure required undermining, layered closure, or tissue rearrangement beyond simple wound approximation
Impact: Separate closure codes can add $200-$800 in additional reimbursement if properly documented and justified based on defect size and complexity
Use diagnosis code specifying benign vs malignant neoplasm and exact anatomic location (shoulder region) to match operative findings
Impact: ICD-10 specificity affects medical necessity determination; vague coding like 'unspecified neoplasm' increases denial risk by 40%
For tumors measuring close to 5 cm threshold (4.8-5.2 cm), document measurement method (caliper, ruler) and whether measured before or after removal to justify code selection

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 23078 in 2025?

The 2025 Medicare national average reimbursement for CPT 23078 is $1,411.28 for both facility and non-facility settings. This rate is based on 43.63 total RVUs (22.55 work RVU, 16.03 PE RVU, 5.05 MP RVU) multiplied by the 2025 conversion factor of 32.3465.

What size tumor qualifies for CPT code 23078 versus 23075?

CPT 23078 requires tumor size of 5 cm or greater in the deepest dimension, while 23075 is used for tumors less than 5 cm. The measurement should be documented from pre-operative imaging and confirmed intraoperatively. Even if only one dimension meets the 5 cm threshold while others are smaller, 23078 is appropriate based on the greatest dimension.

Can CPT 23078 be billed with complex closure codes?

Yes, intermediate (12031-12057) or complex closure codes (13100-13133) may be separately billable with 23078 if the closure required significant additional work beyond simple layered approximation. Documentation must justify the complexity based on defect size, layered closure requirements, or need for undermining and tissue rearrangement. Simple closure is included in the surgical code.

What documentation is needed to prevent denial of CPT 23078?

Essential documentation includes: pre-operative imaging showing tumor size ≥5 cm, operative report with three-dimensional measurements confirming size threshold, description of depth and anatomic location, surgical approach and structures preserved, and pathology report confirming specimen dimensions and tumor type. Medical necessity should be established through symptoms, imaging characteristics, or tissue diagnosis.

Which medical specialties typically bill CPT code 23078?

CPT 23078 is most commonly billed by orthopedic surgeons, particularly those specializing in musculoskeletal oncology, as well as surgical oncologists and general surgeons with experience in soft tissue tumor resection. The procedure requires advanced surgical skills and knowledge of shoulder anatomy to safely resect large masses while preserving neurovascular structures.

Does CPT 23078 require a specific diagnosis code for reimbursement?

While no single diagnosis code is mandated, CPT 23078 requires ICD-10 codes indicating a soft tissue neoplasm of the shoulder region. Appropriate codes include benign neoplasms (D21.11), malignant neoplasms (C49.11-C49.12), or neoplasms of uncertain behavior (D48.11). The diagnosis must match operative findings and pathology, with specific anatomic location (shoulder) documented to support medical necessity.

What is the global period for CPT code 23078?

CPT 23078 has a 90-day global surgical period, meaning all routine post-operative care for 90 days after surgery is included in the reimbursement. Complications requiring return to OR, unrelated E/M services (with modifier 24), or staged procedures (with modifier 58) may be separately billable during this period. Follow-up visits for routine wound checks and therapy are bundled into the global payment.