CPT 23615Surgery

Optx prox humrl fx w/int fix

CPT code 23615 covers surgery to repair a broken upper arm bone (proximal humerus fracture) using screws, plates, or rods to hold the bone pieces in place while they heal.

Showing rates for

National Average

Base Medicare rate

$874.00

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

12.3

PE RVU (NF)

12.28

MP RVU

2.44

Total RVU

27.02

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 the same line as CPT 23615
Impact: Prevents automatic denial; claims without laterality are rejected before adjudication, delaying payment by 2-4 weeks
Document medical necessity for open approach versus percutaneous fixation (23616) by detailing fracture displacement, comminution, and why closed/percutaneous methods were inadequate
Impact: Reduces medical necessity denials by approximately 35%; justifies the higher reimbursement over percutaneous alternatives
Bill for bone graft separately (20900-20902) when harvested from a different site and clearly document the separate incision and procurement
Impact: Additional $150-$400 reimbursement when bone graft is medically necessary and properly documented as a distinct procedure
Use modifier 22 for complex cases with severe comminution, osteoporotic bone requiring augmentation, or revision of prior fixation, with operative note highlighting increased work and time
Impact: Potential additional $175-$437 (20-50% increase) if peer review supports increased complexity; include comparison of standard 90-minute case versus actual time
Verify global period (90 days) and ensure related E/M services within this period are not separately billed unless modifier 24 (unrelated) or 25 (significant, separately identifiable) applies
Impact: Prevents $50-$200 in recoupments from bundled E/M services during global period
When hardware removal is planned, bill 23615 during initial fracture repair and later bill 20680 (removal of implant, deep) with modifier 78 or 79 depending on timing

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23615 in 2025?

The 2025 Medicare national average reimbursement for CPT 23615 is $874 for both facility and non-facility settings, based on a total of 27.02 RVUs and a conversion factor of 32.3465.

What is the difference between CPT 23615 and 23616?

CPT 23615 is open treatment with internal fixation requiring a surgical incision for direct visualization and reduction of the proximal humerus fracture. CPT 23616 is percutaneous fixation using pins or screws inserted through small stab incisions without opening the fracture site. The open approach (23615) reimburses higher due to increased complexity and work RVUs.

Can I bill CPT 23615 with bone graft codes?

Yes, you can separately bill autograft harvesting (20900-20902) or allograft (20930) when bone graft is medically necessary and obtained from a separate site or source. Document the distinct incision for graft harvest and medical necessity. Structural allografts may bundle depending on payer policy.

What modifiers are required when billing CPT 23615?

Laterality modifiers LT (left) or RT (right) are mandatory for every claim. Additional modifiers may include 22 (increased procedural services), 62 (co-surgeons), 80 (assistant surgeon), 54 (surgical care only), or 78 (return to OR during global period) based on specific circumstances.

How many RVUs is CPT code 23615 worth?

CPT 23615 has a total of 27.02 RVUs for 2025, consisting of 12.3 work RVUs, 12.28 practice expense RVUs, and 2.44 malpractice RVUs, making it a high-value orthopedic procedure code.

What is the global period for CPT 23615?

CPT 23615 has a 90-day global surgical period, meaning all routine postoperative care for 90 days after surgery is included in the reimbursement. Separately billable E/M services during this period require modifier 24 (unrelated) or 25 (significant, separately identifiable on same day as surgery).

When should I use modifier 22 with CPT 23615?

Use modifier 22 when the proximal humerus fracture repair involves substantially greater work than typical, such as severe comminution requiring extended operative time, revision of prior hardware, significant osteoporosis requiring bone cement augmentation, or morbid obesity complicating access. Document increased complexity thoroughly with operative time comparison and detailed narrative to support 20-50% additional reimbursement.