CPT 23106Surgery

Incision of collarbone joint

CPT 23106 covers a surgical procedure where the physician makes an incision into the sternoclavicular joint (where the collarbone meets the breastbone) to drain infection, remove damaged tissue, or perform other therapeutic interventions.

Showing rates for

National Average

Base Medicare rate

$503.31

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

6.13

PE RVU (NF)

8.17

MP RVU

1.26

Total RVU

15.56

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

NCCI bundling edits

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Billing tips

Document extensive debridement separately with 11044-11047 if significant soft tissue or bone debridement extends beyond joint capsule
Impact: Additional $150-$400 reimbursement depending on depth and extent of debridement documented
Appeal modifier 22 denials with detailed operative report, comparison to typical procedure time, and quantification of additional work (e.g., 'procedure required 90 minutes vs typical 45 minutes due to extensive purulent material')
Impact: Successful modifier 22 appeals can add $100-$250 to base reimbursement for this code
Verify medical necessity documentation includes failed conservative treatment (antibiotics, aspiration) before surgical intervention to prevent denial
Impact: Prevents denial of entire $503.31 claim; payers commonly deny without documented conservative treatment failure
Bill facility and anesthesia services separately; ensure anesthesia provider uses appropriate base units for upper extremity/shoulder procedures
Impact: Facility can capture additional $2,000-$5,000 depending on setting; ensures all components of care are reimbursed
Capture culture and pathology specimens separately (88305 for tissue pathology, 87070-87077 for cultures) as these are not bundled
Impact: Additional $50-$150 for laboratory services commonly overlooked in infectious cases
For revision procedures or patients with prior sternoclavicular surgery, document clearly in operative note to support modifier 22 or separate coding
Impact: Prevents downcoding or denial; supports higher reimbursement when complexity is documented

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23106 in 2025?

The 2025 Medicare national average reimbursement for CPT 23106 is $503.31 for both facility and non-facility settings. This is based on 15.56 total RVUs (6.13 work RVU, 8.17 PE RVU, 1.26 MP RVU) multiplied by the 2025 conversion factor of 32.3465.

Can CPT 23106 be billed bilaterally with modifier 50?

Yes, CPT 23106 can be billed with modifier 50 when the procedure is performed on both sternoclavicular joints during the same operative session. Bilateral procedures typically reimburse at 150% of the unilateral rate when medically necessary and properly documented, though payer policies vary.

What diagnosis codes support medical necessity for CPT 23106?

Common supporting diagnoses include septic arthritis of the sternoclavicular joint (M00.21-M00.29), osteomyelitis of the clavicle (M86.31-M86.319), abscess of shoulder region (L02.41-L02.42), traumatic arthropathy (M12.51-M12.52), and post-procedural infection (T81.4XXA). Documentation must link the surgical intervention to the specific diagnosis.

Is CPT 23106 subject to the global surgical package?

Yes, CPT 23106 is a major surgical procedure with a 90-day global period. This includes preoperative evaluation (typically 1 day before), the procedure itself, and 90 days of routine postoperative care. Any complications or unrelated services during this period require appropriate modifiers (24, 78, 79) for separate reimbursement.

What modifiers are most commonly used with CPT 23106?

The most common modifiers include LT/RT (laterality), modifier 22 (increased procedural services for complex cases), modifier 59 (distinct procedural service), modifier 78 (return to OR for complication), and modifier 50 (bilateral procedure). Modifier 22 requires detailed documentation of increased complexity to justify additional reimbursement.

Can debridement be billed separately with CPT 23106?

Debridement codes 11044-11047 may be separately billable if the debridement extends significantly beyond the joint capsule into surrounding soft tissue, muscle, or bone and is clearly documented as distinct from the joint incision. Use modifier 59 to indicate the debridement was a separate, identifiable service. Minor debridement within the joint is considered included in 23106.

What documentation is required to prevent denials for CPT 23106?

Required documentation includes preoperative diagnosis with specific joint identification, evidence of failed conservative treatment (antibiotics, imaging, aspiration attempts), detailed operative report describing pathology encountered, interventions performed, cultures obtained, and medical necessity justification. High-quality documentation of infection severity and surgical complexity is critical for claims approval and audit defense.