CPT 23172Surgery

Remove shoulder blade lesion

CPT code 23172 covers the surgical removal of a growth or abnormal tissue from the shoulder blade (scapula). This is an open surgical procedure that requires cutting through skin and tissue to access and remove the lesion.

Showing rates for

National Average

Base Medicare rate

$569.62

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

7.31

PE RVU (NF)

8.8

MP RVU

1.5

Total RVU

17.61

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

NCCI bundling edits

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Billing tips

Document exact lesion dimensions (length, width, depth in cm) and anatomic location on scapula (body, spine, acromion, glenoid) in operative report
Impact: Supports medical necessity and prevents downcoding; required for modifier 22 consideration if lesion >5cm or complex location
Always send pathology report with initial claim for malignant or indeterminate lesions to establish medical necessity
Impact: Reduces denial rate by approximately 40% and accelerates claim processing; critical for payers requiring pre-service authorization
Bill separately for frozen section pathology (88331) when performed intraoperatively to assess margins
Impact: Additional $60-120 reimbursement per specimen; not bundled with 23172
Use correct laterality modifier (RT/LT) on every claim; many payers now reject claims without anatomic modifiers
Impact: Prevents automatic denials and claim suspension; required by NCCI edits effective 2020
For lesions requiring bone grafting after excision, separately report bone graft codes (20900-20902) with modifier 51
Impact: Additional $200-400 reimbursement depending on graft type and source; ensure documentation supports separate procedure
Verify prior authorization requirements before surgery; many payers require pre-approval for scapular bone procedures
Impact: Eliminates potential 100% claim denial; authorization turnaround typically 3-5 business days

Applicable modifiers

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23172 in 2025?

The 2025 Medicare national average reimbursement for CPT 23172 is $569.62 for both facility and non-facility settings. This is based on 17.61 total RVUs multiplied by the 2025 conversion factor of $32.3465.

How many RVUs is CPT code 23172 worth?

CPT 23172 has 17.61 total RVUs, broken down as 7.31 work RVUs, 8.8 practice expense RVUs (both facility and non-facility), and 1.5 malpractice RVUs.

What is the difference between CPT 23172 and soft tissue shoulder lesion excision codes?

CPT 23172 is specifically for excision of lesions involving the scapular bone and requires bone resection or curettage. Soft tissue excision codes (23075-23077) are for masses in muscle, fascia, or subcutaneous tissue without bone involvement. Documentation must clearly show bone pathology to support 23172.

Does CPT 23172 require prior authorization from insurance?

Most commercial payers and Medicare Advantage plans require prior authorization for CPT 23172 due to its surgical nature and hospital setting. Traditional Medicare does not require authorization but may have Local Coverage Determinations (LCDs) with specific documentation requirements. Verify with individual payer before scheduling.

Can CPT 23172 be billed with shoulder arthroscopy codes?

CPT 23172 can be billed with shoulder arthroscopy codes (29805-29828) if the procedures are distinct and unrelated, using modifier 59 or XS. However, if the arthroscopy is merely exploratory or related to the same pathology, bundling may occur. Documentation must clearly justify separate procedures addressing different conditions.

What diagnosis codes support medical necessity for CPT 23172?

Common supporting ICD-10 codes include D16.01 (benign neoplasm of scapula), C40.01 (malignant neoplasm of scapula), M85.61 (other cyst of bone, shoulder), D48.0 (neoplasm of uncertain behavior of bone), and M89.9 (disorder of bone, unspecified). The diagnosis must correlate with pathology findings and pre-operative imaging.

Is CPT 23172 covered for both inpatient and outpatient settings?

Yes, CPT 23172 can be performed and billed in both inpatient hospital, hospital outpatient department, and ambulatory surgery center settings. The Medicare facility and non-facility rates are the same at $569.62 for 2025. Setting choice depends on patient complexity, lesion characteristics, and facility capabilities.