CPT 23195Surgery

Removal of head of humerus

CPT code 23195 covers the surgical removal of the head of the humerus (the ball-shaped top portion of the upper arm bone that forms part of the shoulder joint). This is typically performed when the humeral head is severely damaged by trauma, infection, or degenerative disease.

Showing rates for

National Average

Base Medicare rate

$742.68

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

10.36

PE RVU (NF)

10.55

MP RVU

2.05

Total RVU

22.96

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

NCCI bundling edits

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Billing tips

Document whether procedure is staged reconstruction or permanent resection arthroplasty, as this affects medical necessity and follow-up care expectations
Impact: Clear documentation prevents denials for subsequent reconstruction procedures and establishes appropriate global period considerations
Separately bill for bone grafting (20900-20902) or complex soft tissue repair if performed, as these are not included in 23195
Impact: Can add $150-500 in additional reimbursement when properly documented as distinct from humeral head removal
Use modifier 22 with detailed operative note when infection requires extensive debridement beyond standard resection, including time documentation
Impact: Can increase reimbursement from $742.68 to $890-1,114 with proper justification of 20-50% additional work
Verify that 23195 is not bundled with subsequent shoulder arthroplasty if performed in staged fashion; ensure adequate time separation (typically 90 days)
Impact: Prevents denial of second procedure valued at $1,500-3,000 for shoulder reconstruction
Document medical necessity clearly when performed for non-fracture indications, including failed conservative treatment and infection control attempts
Impact: Reduces denial rate by 30-40% for cases outside typical trauma scenarios; supports medical necessity review
Bill facility and non-facility settings at same rate ($742.68) but ensure place of service code matches actual location to avoid claim edits
Impact: Prevents automatic claim rejection; both settings reimburse identically for this code but require accurate POS coding

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23195 in 2025?

The 2025 Medicare national average reimbursement for CPT 23195 is $742.68 for both facility and non-facility settings. This is based on 22.96 total RVUs (10.36 work RVU, 10.55 practice expense RVU, 2.05 malpractice RVU) multiplied by the 2025 conversion factor of 32.3465.

Does CPT 23195 include shoulder arthroplasty or implant placement?

No, CPT 23195 covers only the removal (resection) of the humeral head without prosthetic replacement. If a shoulder arthroplasty with humeral component is performed during the same session, the appropriate arthroplasty code (23470, 23472) should be billed instead, as those codes include the resection component.

When should modifier 22 be used with CPT 23195?

Modifier 22 should be appended to CPT 23195 when the procedure requires substantially greater work than typical, such as extensive infection requiring radical debridement, tumor involvement necessitating wide margins, severe scarring from multiple prior surgeries, or unusual anatomy significantly increasing complexity. Documentation must include specific details of additional time and work performed, typically increasing procedure time by 25% or more.

Can CPT 23195 be billed for removal of a shoulder prosthesis component?

No, CPT 23195 is for resection of the native humeral head bone. Removal of a prosthetic humeral component should be coded with 23334 (removal of prosthesis, includes humeral and glenoid components) or 23335 (removal with bone graft for allograft or autograft reconstruction). Using 23195 for prosthesis removal will result in denial or incorrect payment.

What diagnosis codes commonly support medical necessity for CPT 23195?

Common supporting ICD-10 codes include S42.2 (fracture of upper end of humerus), M87.021-M87.022 (osteonecrosis of right/left humerus), M86.121-M86.122 (acute osteomyelitis of humerus), M00.811-M00.812 (arthritis of shoulder due to infection), C40.01-C40.02 (malignant neoplasm of scapula and long bones of upper limb), and T84.011A-T84.012A (broken internal joint prosthesis, shoulder). Documentation must show resection is medically necessary and appropriate treatment.

How does CPT 23195 differ from CPT 23174 and 23184?

CPT 23174 is radical resection of tumor including humeral head (much more extensive oncologic procedure), CPT 23184 is partial excision of clavicle or scapula (different bones), while CPT 23195 specifically covers removal of the humeral head only. CPT 23195 is less extensive than 23174 and involves different anatomy than 23184. The correct code depends on which bone structure was resected and whether radical tumor margins were required.

Is prior authorization typically required for CPT 23195?

Most Medicare Advantage plans and commercial payers require prior authorization for CPT 23195 as it is an inpatient or high-cost outpatient surgical procedure. Traditional Medicare does not require prior authorization but may conduct retrospective medical necessity review. Contact the specific payer to verify authorization requirements at least 2-3 weeks before scheduled surgery to avoid claim denials for lack of authorization.