CPT 23156Surgery

Removal of humerus lesion

CPT code 23156 covers the surgical removal of a lesion (abnormal growth or tissue) from the humerus, which is the upper arm bone between the shoulder and elbow. This procedure typically involves making an incision, removing the abnormal tissue, and may include bone grafting or repair.

Showing rates for

National Average

Base Medicare rate

$676.69

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

9.11

PE RVU (NF)

9.93

MP RVU

1.88

Total RVU

20.92

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

NCCI bundling edits

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Billing tips

Always append laterality modifier (LT or RT) on initial claim submission
Impact: Prevents automatic denial or claim suspension requiring resubmission; saves 15-30 day payment delay
Document lesion size, location on humerus (proximal, mid-shaft, distal), and depth to justify code selection over simpler excision codes
Impact: Prevents downcoding to lower-paying soft tissue excision codes (11400 series at $150-300) representing $400+ loss
When bone grafting is performed, report separately with 20900-20902 and modifier 51 as add-on procedures are not bundled
Impact: Additional $200-500 reimbursement depending on graft source and size when properly documented
Submit pathology report with claim or appeal to confirm lesion presence and justify medical necessity
Impact: Reduces medical necessity denials by 60-70% and expedites claim processing on initial submission
Use modifier 22 with detailed operative note when lesion involves neurovascular structures or requires significantly extended operative time (>50% longer than typical)
Impact: Potential additional $135-270 when approved; include comparison of typical vs actual operative time in documentation
Verify pre-authorization requirements for commercial payers as bone tumor excision often requires prior approval
Impact: Prevents complete claim denial; non-authorized claims may be denied 100% of $676.69 reimbursement

Common denials

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23156 in 2025?

The 2025 Medicare national average reimbursement for CPT 23156 is $676.69 for both facility and non-facility settings, based on 20.92 total RVUs and the 2025 conversion factor of 32.3465.

What is the difference between CPT 23156 and 23220?

CPT 23156 covers removal of a humerus lesion with intralesional or marginal excision, while CPT 23220 represents radical resection of a bone tumor with wide margins, typically for malignancies. Code 23220 involves more extensive bone removal, reconstruction, and carries significantly higher RVUs and reimbursement.

Can I bill bone graft separately with CPT 23156?

Yes, bone grafting can be reported separately using codes 20900-20902 depending on graft type and source. These are not bundled with 23156 but should be reported with modifier 51 for multiple procedures, and documentation must clearly show the graft was necessary and performed.

What diagnosis codes support medical necessity for CPT 23156?

Common supporting ICD-10 codes include D16.01 (benign neoplasm of scapula and long bones of upper limb), M85.50-M85.59 (bone cyst), D48.0 (neoplasm of uncertain behavior of bone), and C40.01-C40.02 (malignant neoplasm of humerus). Documentation must link imaging findings to the diagnosis.

Is CPT 23156 performed inpatient or outpatient?

CPT 23156 can be performed in either setting depending on lesion complexity, patient comorbidities, and anticipated recovery needs. The 2025 Medicare rate is identical ($676.69) for both facility and non-facility settings, though commercial payers may have different site-of-service requirements.

How many RVUs is CPT code 23156 worth?

CPT 23156 has 20.92 total RVUs in 2025, broken down as: 9.11 work RVUs, 9.93 practice expense RVUs (both facility and non-facility), and 1.88 malpractice RVUs. This represents a moderately complex orthopedic surgical procedure.

What modifiers are required when billing CPT 23156?

Laterality modifiers (LT for left, RT for right) are required on every claim for CPT 23156. Additional modifiers like 22 (increased complexity), 58 (staged procedure), or 59 (distinct service) may be appropriate based on specific clinical circumstances but are not universally required.