CPT 23395Surgery

Muscle transfer shoulder/arm

CPT code 23395 covers surgical procedures where a muscle is transferred from one location to another in the shoulder or upper arm area. This is typically done to restore function when the original muscle is damaged, torn, or non-functional.

Showing rates for

National Average

Base Medicare rate

$1,264.10

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

18.54

PE RVU (NF)

16.86

MP RVU

3.68

Total RVU

39.08

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

NCCI bundling edits

Loading bundling edits…

Billing tips

Document specific muscles transferred (latissimus dorsi, pectoralis major, trapezius) and detailed surgical approach in operative report
Impact: Prevents medical necessity denials and downcoding; can mean difference between full $1264.10 payment versus denial
For complex cases with extensive scarring or revision surgery, append modifier 22 with comprehensive documentation showing increased work
Impact: Potential additional $250-$630 in reimbursement (20-50% increase) with successful appeal
Verify pre-authorization requirements as most payers require prior authorization for muscle transfer procedures
Impact: Prevents 100% claim denial; retroactive authorization rarely granted for elective reconstructive procedures
Code any necessary tendon repairs or capsular reconstruction separately if not inherent to the muscle transfer
Impact: Additional $300-$800 in reimbursement for distinct procedures with modifier 59 when appropriate
Bill facility and non-facility rates appropriately; both are $1264.10 for this code but verify site of service matches claim form
Impact: Ensures accurate processing; site of service mismatches can delay payment 30-60 days
Submit diagnostic imaging reports (MRI, CT) showing rotator cuff pathology or muscle deficiency to support medical necessity
Impact: Reduces denial rate by 40-60%; appeals without imaging have low success rate for this procedure

Common denials

Live Field Datano reports yet

Real billers contribute denial patterns and appeal strategies for this code. Once 5+ reports come in, you’ll see live aggregated data here — the only place this exists, free.

Working with CPT 23395?

Get the free Revenue Protection Toolkit — the denial triggers, modifier pitfalls, and bundling conflicts that quietly cost you reimbursement. Instant download.

Help build the field knowledge

MedPayIQ gets smarter as billers contribute. If you've had this code denied, share what happened so others learn from it. Anonymous, no patient info.

Related actions

Frequently asked questions

What is the Medicare reimbursement rate for CPT 23395 in 2025?

The 2025 Medicare national average reimbursement for CPT 23395 is $1264.10 for both facility and non-facility settings, based on 39.08 total RVUs and a conversion factor of 32.3465.

How many RVUs is CPT code 23395 worth?

CPT 23395 has 39.08 total RVUs, consisting of 18.54 work RVUs, 16.86 practice expense RVUs, and 3.68 malpractice RVUs according to the 2025 Medicare Physician Fee Schedule.

Does CPT 23395 require prior authorization?

Most commercial payers and Medicare Advantage plans require prior authorization for CPT 23395 due to its complex nature and high reimbursement. Traditional Medicare does not require prior authorization but may conduct post-payment review.

Can CPT 23395 be billed bilaterally?

Yes, CPT 23395 can be billed bilaterally using modifier 50 if muscle transfers are performed on both shoulders during the same operative session, though this is clinically rare. Bilateral billing increases total reimbursement to 150% of the single procedure rate.

What documentation is required to bill CPT 23395?

Required documentation includes pre-operative imaging showing irreparable muscle damage, evidence of failed conservative treatment for 3-6 months, detailed operative report specifying donor muscle and recipient site, surgical approach, fixation method, and post-operative rehabilitation plan.

What is the difference between CPT 23395 and 23397?

CPT 23395 is for muscle transfer in the shoulder/arm region, while 23397 is for muscle transfer with microvascular anastomosis (free flap). Code 23397 involves reconnecting blood vessels under microscope and has significantly higher reimbursement due to increased complexity.

How long is the global period for CPT 23395?

CPT 23395 has a 90-day global period, meaning all routine post-operative care within 90 days of surgery is included in the procedure payment. Any complications or unrelated services during this period require appropriate modifiers for separate reimbursement.