CPT 23155Surgery

Removal of humerus lesion

CPT code 23155 covers surgical removal of an abnormal growth or lesion from the humerus (upper arm bone). This procedure typically requires open surgical access to excise benign or malignant bone tumors, cysts, or other abnormal tissue.

Showing rates for

National Average

Base Medicare rate

$791.84

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

10.86

PE RVU (NF)

11.39

MP RVU

2.23

Total RVU

24.48

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

NCCI bundling edits

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Billing tips

Document lesion size, depth, and relationship to neurovascular structures in operative report to support medical necessity and complexity
Impact: Prevents denials for insufficient documentation; supports modifier 22 claims for complex cases potentially increasing payment by $158-395
Verify pre-authorization requirements as many payers classify 23155 as requiring prior approval for bone tumor excision
Impact: Prevents complete claim denial; saves average $791.84 per case and reduces administrative appeal costs
Distinguish between CPT 23155 (lesion removal) and 23140/23145 (bone excision) based on whether the procedure targets a discrete lesion versus segmental bone resection
Impact: Correct code selection prevents downcoding; 23155 pays $791.84 vs potential lower rates for incorrectly selected codes
Bundle pathology charges separately using appropriate CPT 88305 or 88307 codes for specimen examination, not included in 23155
Impact: Additional $75-150 in pathology reimbursement when properly documented and billed separately
Use appropriate laterality modifiers (LT/RT) as Medicare and most commercial payers require this for all musculoskeletal procedures
Impact: Prevents claim rejection and processing delays averaging 15-30 days for resubmission
Document any bone grafting or reconstruction separately as these are not included in 23155 base code; consider CPT 20900-20902 series
Impact: Additional $200-600 reimbursement for bone graft procedures when medically necessary and properly documented

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23155 in 2025?

The 2025 Medicare national average reimbursement for CPT 23155 is $791.84 for both facility and non-facility settings. This rate is based on 24.48 total RVUs (10.86 work RVU, 11.39 practice expense RVU, and 2.23 malpractice RVU) multiplied by the 2025 conversion factor of 32.3465.

What is the difference between CPT 23155 and 23140 for humerus procedures?

CPT 23155 is specifically for removal of a discrete lesion from the humerus (such as a tumor or cyst), while CPT 23140 describes excision or curettage of a bone cyst or benign tumor of the proximal humerus with possible autograft. Code selection depends on the specific pathology, anatomic location, and surgical technique documented in the operative report.

Does CPT 23155 require prior authorization from insurance?

Most commercial payers and Medicare Advantage plans require prior authorization for CPT 23155 as it is classified as a surgical bone tumor procedure. Traditional Medicare does not require prior authorization, but documentation of medical necessity through imaging and pathology is essential for claim approval.

Can CPT 23155 be billed bilaterally with modifier 50?

Yes, CPT 23155 can be billed with modifier 50 if lesions are removed from both the left and right humerus during the same operative session. Bilateral billing typically results in 150% of the base rate ($1,187.76 total), though individual payer policies may vary.

What documentation is required to bill CPT 23155 successfully?

Required documentation includes pre-operative imaging confirming the lesion, detailed operative report with lesion size and location, description of surgical approach and excision technique, pathology report confirming tissue diagnosis, laterality specification, and medical necessity statement explaining why surgical removal was required.

How many RVUs is CPT code 23155 worth in 2025?

CPT 23155 has a total of 24.48 RVUs in 2025, consisting of 10.86 work RVUs, 11.39 practice expense RVUs (both facility and non-facility), and 2.23 malpractice RVUs according to the CMS Medicare Physician Fee Schedule RVU25A released December 23, 2024.

Can bone grafting be billed separately with CPT 23155?

Yes, bone grafting procedures (CPT 20900-20902 series) can typically be billed separately from CPT 23155 when medically necessary and performed as a distinct procedure to fill the defect created by lesion removal. Documentation must clearly support the medical necessity and distinct nature of the bone graft procedure, and modifier 59 may be required to prevent bundling denials.