CPT 23190Surgery

Partial removal of scapula

CPT code 23190 covers the partial surgical removal of the scapula (shoulder blade), typically performed to treat bone tumors, severe infections, or significant trauma to this area.

Showing rates for

National Average

Base Medicare rate

$574.15

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

7.47

PE RVU (NF)

8.75

MP RVU

1.53

Total RVU

17.75

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

NCCI bundling edits

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Billing tips

Document tumor size, location, and margin requirements in operative report to support modifier 22 claims for increased complexity
Impact: Can justify additional $114-$287 reimbursement (20-50% increase) for complex cases with proper documentation
Always append laterality modifier (LT/RT) as primary modifier before any other modifiers; this is a Medicare LCD requirement for shoulder procedures
Impact: Prevents automatic denial; missing laterality results in 100% claim rejection requiring resubmission and payment delay
Verify medical necessity with appropriate ICD-10 codes (C40.01/C40.02 for malignant bone neoplasm, M86.311/M86.312 for chronic osteomyelitis) before scheduling
Impact: Prevents denial for lack of medical necessity; oncologic and infectious indications have highest approval rates
Bill separately for bone pathology (88305-88309) if specimen sent for frozen section or permanent pathology during procedure
Impact: Additional $50-$200 depending on pathology complexity; often overlooked revenue opportunity
For hospital billing, ensure implants, bone graft materials, or reconstruction devices are properly captured as separate charges with appropriate C-codes
Impact: Hospitals can recover $1,000-$10,000 in device costs depending on reconstruction complexity
Document operative time and specific technical difficulties when billing with modifier 22, including comparative time to standard procedure (typically 2-3 hours baseline)
Impact: Increases modifier 22 approval rate from approximately 30% to 70% with comprehensive documentation

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23190 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 23190 is $574.15 for both facility and non-facility settings, based on 17.75 total RVUs and a conversion factor of 32.3465.

Can CPT 23190 be billed bilaterally with modifier 50?

While anatomically possible, bilateral partial scapulectomy performed in the same operative session is extremely rare. If performed bilaterally, use modifier 50 and expect individual payer review for medical necessity. Most cases involve unilateral pathology requiring LT or RT modifier only.

What diagnosis codes support medical necessity for CPT 23190?

Primary supporting diagnoses include C40.01/C40.02 (malignant bone neoplasm of scapula), D16.01/D16.02 (benign bone neoplasm), M86.311/M86.312 (chronic multifocal osteomyelitis), S42.101A-S42.199A (scapular fractures with complications), and M87.219 (radiation necrosis of bone).

How does CPT 23190 differ from CPT 23182?

CPT 23190 is partial removal of the scapula bone itself, while CPT 23182 is partial removal of the clavicle. These are distinct anatomical structures requiring different surgical approaches and cannot be confused for coding purposes. Always verify which bone is being resected.

What is the global period for CPT 23190?

CPT 23190 has a 90-day global surgical package. All routine post-operative care, including cast/splint management, wound checks, and rehabilitation oversight within 90 days is included in the $574.15 payment. Complications requiring return to OR use modifier 78.

Can CPT 23190 be performed in an ASC or must it be hospital-based?

While CPT 23190 appears on the ASC approved procedure list with the same facility rate ($574.15), most payers and surgical guidelines recommend hospital-based surgery due to potential for significant blood loss, duration of surgery, and post-operative monitoring requirements. Case selection criteria vary by payer.

How should reconstruction following partial scapulectomy be coded?

Reconstruction is typically included in CPT 23190 if performed during the same operative session for basic closure and stabilization. Extensive reconstruction requiring bone grafting, prosthetic implants, or complex soft tissue transfers may warrant separate coding with modifier 59 and detailed documentation supporting distinct procedures (e.g., 20926 for tissue graft, 23472 for glenoid reconstruction if applicable).