CPT 23620Surgery

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CPT code 23620 covers non-surgical treatment of a fracture to the greater tuberosity of the humerus (the bony bump at the top of the upper arm bone near the shoulder). The physician treats the fracture without performing surgery or manipulating the bone fragments.

Showing rates for

National Average

Base Medicare rate

$278.83

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

2.55

PE RVU (NF)

5.57

MP RVU

0.5

Total RVU

8.62

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

NCCI bundling edits

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Billing tips

Append RT or LT modifier for laterality - Medicare and most commercial payers require anatomical modifiers for bilateral structures
Impact: Prevents automatic denials and claim rejections; claims without laterality modifiers may be rejected or pended, delaying payment by 15-30 days
Bill in facility setting (ED, hospital outpatient) when applicable to receive correct rate - verify place of service code matches actual location
Impact: Facility rate is $266.86 vs non-facility $278.83; incorrect POS coding can trigger audits and recoupment
Do not separately bill E/M on same day unless significant, separately identifiable service documented with modifier 25 - initial fracture care includes evaluation
Impact: Unbundling E/M from fracture care without proper documentation risks $100-150 denial plus potential fraud investigation
Document that NO manipulation was performed - any attempt to reduce or manipulate fragments upgrades to CPT 23625 which reimburses at higher rate
Impact: CPT 23625 (with manipulation) pays approximately $100-150 more; downcoding from 23625 to 23620 during audit represents significant revenue loss
Global period is 90 days - all routine follow-up care including repeat X-rays interpretation, cast/immobilizer adjustments, and office visits are bundled
Impact: Billing separately for included services during global period results in denials; understand $278.83 covers all related care for 90 days
Use modifier 54 when ED physician provides initial treatment but patient will follow with private orthopedist - coordinate transfer of care documentation

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Frequently asked questions

What is the 2025 Medicare reimbursement for CPT 23620?

The 2025 Medicare national average reimbursement for CPT 23620 is $278.83 for non-facility settings and $266.86 for facility settings. These rates are based on the CMS Physician Fee Schedule with a conversion factor of 32.3465 and total RVUs of 8.62.

Does CPT 23620 include follow-up visits after the initial fracture treatment?

Yes, CPT 23620 has a 90-day global period, meaning all routine follow-up care is included in the reimbursement. This includes follow-up office visits, repeat X-rays for fracture healing assessment, immobilizer adjustments, and routine postoperative care. You cannot bill separately for these services during the global period.

What is the difference between CPT 23620 and 23625?

CPT 23620 is for closed treatment WITHOUT manipulation, while CPT 23625 is for closed treatment WITH manipulation. If the physician actively manipulates or reduces the fracture fragments (requiring force to reposition the bone), use 23625. If the fracture is simply immobilized without attempted reduction, use 23620. Documentation must clearly support which procedure was performed.

Can I bill an E/M code with CPT 23620 on the same day?

Generally, no. The initial evaluation of the fracture is included in CPT 23620. However, you may bill a separate E/M with modifier 25 if there is a significant, separately identifiable service beyond the decision for fracture care (such as evaluation of other injuries or unrelated conditions). Documentation must clearly support the separate service.

Is modifier RT or LT required for CPT 23620?

Yes, Medicare and most commercial payers require laterality modifiers (RT for right, LT for left) for CPT 23620 because the shoulder is a bilateral structure. Failing to append the appropriate modifier will result in claim rejection or denial for incomplete coding.

How many RVUs is CPT 23620 worth in 2025?

CPT 23620 has a total of 8.62 RVUs in 2025, consisting of 2.55 work RVUs, 5.57 non-facility practice expense RVUs (5.2 facility), and 0.5 malpractice RVUs. These values are from the CMS Medicare Physician Fee Schedule RVU25A released December 23, 2024.

What diagnosis codes are typically used with CPT 23620?

CPT 23620 is typically paired with ICD-10 codes for greater tuberosity fractures of the humerus, such as S42.251A-S42.256A (displaced fracture, initial encounter) or S42.261A-S42.266A (nondisplaced fracture, initial encounter). The specific code depends on laterality (right/left), displacement status, and encounter type (initial, subsequent, sequela).