CPT 23616Surgery

Optx prx hmrl fx fix rpr rpl

CPT 23616 covers surgical repair of a broken upper arm bone (proximal humerus) near the shoulder, where the surgeon uses pins, plates, or screws to hold the bone pieces together while they heal.

Showing rates for

National Average

Base Medicare rate

$1,212.67

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

18.37

PE RVU (NF)

15.47

MP RVU

3.65

Total RVU

37.49

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

NCCI bundling edits

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Billing tips

Verify fracture classification and complexity in operative note matches procedure chosen - 23616 is for proximal humeral fractures requiring fixation; simpler 2-part fractures without displacement may only qualify for percutaneous pinning (23605) at lower rate
Impact: Incorrect code selection can result in $400-600 underpayment or trigger audit if upcoding from 23605
Document all hardware used (number of screws, plate type, brand if implant-intensive) to support medical necessity and justify modifier 22 if applicable
Impact: Modifier 22 with proper documentation can increase reimbursement by $242-606 for complex cases
Bill facility vs non-facility setting correctly - this code has identical rates ($1212.67) but setting impacts facility fees and some payers apply different policies
Impact: Place of service errors cause claim rejections requiring resubmission and payment delays of 30-60 days
Separate any arthroscopic procedures performed during same session with appropriate modifiers - common scenario is diagnostic arthroscopy converted to open ORIF
Impact: Unbundled arthroscopy codes without modifier 59 or XS face bundling denials, losing $300-800 in legitimate reimbursement
Submit laterality modifier (LT/RT) on initial claim submission to avoid automatic rejection by Medicare and commercial payers
Impact: Missing laterality causes immediate denial, delaying payment 14-30 days for corrected claim reprocessing
Code tuberosity repair separately only if performed as distinct procedure outside global period - 23616 includes tuberosity repair/replacement as integral component

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23616 in 2025?

Medicare pays $1212.67 for CPT 23616 in 2025 (national average for both facility and non-facility settings). This rate is based on 37.49 total RVUs multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary by geographic locality based on GPCI adjustments.

What is the difference between CPT 23616 and 23615?

CPT 23615 covers open treatment of proximal humeral fracture WITHOUT internal fixation (typically held with sutures, wires, or external immobilization only), while 23616 includes internal fixation with plates, screws, or nails. Code 23616 reimburses significantly higher due to the complexity of hardware placement and has higher RVUs (37.49 vs lower for 23615).

Can I bill CPT 23616 with shoulder arthroscopy on the same day?

Yes, but requires careful modifier use. If arthroscopy is diagnostic and converted to open ORIF, or if treating distinct pathology, append modifier 59 or XS to the arthroscopy code. Documentation must clearly show separate procedures with distinct purposes. Without proper modifiers and documentation, payers will bundle the arthroscopy into 23616 under NCCI edits.

What documentation is required to support CPT 23616?

Required documentation includes: complete fracture classification (Neer or AO/OTA), pre-operative imaging confirming displacement/comminution requiring open fixation, detailed operative note describing surgical approach, reduction technique, specific hardware used (type, number, size), tuberosity status and repair if applicable, fluoroscopic confirmation of reduction, and laterality throughout. Insufficient documentation commonly triggers denials or audits.

How many RVUs is CPT code 23616 worth?

CPT 23616 has 37.49 total RVUs for 2025, broken down as: 18.37 work RVUs, 15.47 practice expense RVUs (both facility and non-facility), and 3.65 malpractice RVUs. This high RVU value reflects the complexity and time required for open proximal humerus fracture fixation.

Does CPT 23616 include tuberosity repair?

Yes, CPT 23616 specifically includes repair or replacement of the tuberosity (greater or lesser) as stated in the code descriptor. Separately billing tuberosity repair codes like 23630 with 23616 will trigger NCCI bundling edits and denials. The tuberosity work is considered integral to the proximal humerus fracture fixation.

What is the global period for CPT 23616?

CPT 23616 has a 90-day global surgical period. This means all routine follow-up care for 90 days post-operatively is included in the $1212.67 payment. Any related procedures during this period require modifiers (78 for complications, 58 for staged procedures, 79 for unrelated procedures) to receive separate payment.