CPT 23630Surgery

Optx gr hmrl tbrs fx int fix

CPT code 23630 covers the surgical repair of a broken shoulder bone called the greater tuberosity of the humerus, using pins, plates, or screws to hold the bone pieces in place. This is an open surgery where the surgeon makes an incision to directly access and fix the fracture.

Showing rates for

National Average

Base Medicare rate

$775.67

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

10.57

PE RVU (NF)

11.3

MP RVU

2.11

Total RVU

23.98

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

NCCI bundling edits

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Billing tips

Always append laterality modifiers (LT or RT) to avoid automatic denials. Medicare requires laterality for all bilateral anatomic structures since 2011.
Impact: Prevents 100% of payment delays and denials related to missing laterality. Claims without laterality modifiers are rejected at clearinghouse or suspended at payer.
Document displacement measurements in millimeters and rotator cuff involvement in the operative report. Medical necessity often hinges on demonstrating >5mm displacement or associated soft tissue injury.
Impact: Reduces denials for medical necessity by approximately 40-60%. Payers frequently request records to verify surgical indication versus conservative management.
Verify facility versus non-facility status before claim submission. While both settings reimburse at $775.67 for this code, place of service codes 21-24 (hospital settings) require facility rates.
Impact: Ensures accurate reimbursement and prevents recoupment. Mismatched POS codes can trigger audits and payment adjustments.
Bill radiological supervision and interpretation separately (77002 for fluoroscopy) when performed and documented by the surgeon. This is not bundled into 23630 per NCCI edits.
Impact: Additional $50-75 revenue per case when fluoroscopic guidance is documented. Medicare allows separate payment without modifier when performed by different specialty.
Use modifier 22 with detailed operative note when case complexity exceeds typical scenarios (comminution, prior hardware, extensive soft tissue damage). Include comparison of typical versus actual operative time.
Impact: Potential additional $155-233 (20-30% increase) when properly documented with manual review. Include detailed letter of medical necessity with claim.

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Related actions

Common denials

Medical necessity denial - payer claims fracture could have been managed conservatively without surgery based on displacement <5mm or minimal functional impairment.

How to appeal: Submit appeal with pre-operative imaging reports documenting displacement measurements, functional assessment notes showing shoulder dysfunction, and peer-reviewed literature supporting surgical indication for the specific fracture pattern. Include surgeon's attestation explaining why conservative management was inappropriate for this patient's specific circumstances (age, activity level, rotator cuff involvement).

Incorrect code assignment - payer downcodes to 23615 (ORIF proximal humeral fracture) or 23665 (closed treatment) based on documentation review.

How to appeal: Provide operative report with highlighted sections clearly identifying the fracture as isolated to the greater tuberosity, not involving the surgical neck or humeral head. Include anatomic diagrams if necessary. Reference CPT descriptor differences and cite that 23630 specifically addresses greater tuberosity fractures with internal fixation.

Missing or incorrect laterality modifier resulting in claim rejection or suspension at payer level.

How to appeal: Correct and resubmit claim with appropriate LT or RT modifier. If claim was processed without modifier, submit corrected claim with operative report showing laterality documented. Most payers allow timely filing exception for corrected laterality modifiers within 90 days.

Bundling denial when billed with rotator cuff repair (29827, 23410-23412) under NCCI edits - payer bundles as incidental to fracture repair.

How to appeal: Appeal with modifier 59 or XU on the rotator cuff repair code when the tear is distinct and not inherent to the fracture mobilization. Documentation must clearly show the rotator cuff repair was separate, extensive, and not simply reattachment of the tuberosity fragment. Quantify tear size (cm) and describe repair technique separately from fracture fixation.

Frequently asked questions

What is the Medicare reimbursement rate for CPT 23630 in 2025?

The 2025 Medicare national average payment for CPT 23630 is $775.67 for both facility and non-facility settings. This rate is calculated using a total RVU of 23.98 multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary based on geographic location and MAC-specific adjustments.

How many RVUs is CPT code 23630 worth?

CPT 23630 has a total RVU value of 23.98 for 2025, comprised of 10.57 work RVUs, 11.3 practice expense RVUs, and 2.11 malpractice RVUs. This makes it a moderately high-value surgical procedure with significant work and practice expense components.

Can CPT 23630 be billed with a rotator cuff repair code?

Yes, but with caution. CPT 23630 can be billed with rotator cuff repair codes (23410-23412, 29827) when the rotator cuff tear is distinct, substantial, and separate from the fracture mobilization itself. Use modifier 59 or XU on the rotator cuff repair code and document the tear size, location, and that the repair was not simply reattachment of the tuberosity fragment. Many payers scrutinize this combination due to NCCI bundling edits.

What is the difference between CPT 23630 and 23615?

CPT 23630 is specific to open treatment of greater tuberosity fractures with internal fixation, while 23615 covers ORIF of proximal humeral fractures involving the surgical or anatomic neck. The key distinction is anatomic location: 23630 is for isolated tuberosity fractures, whereas 23615 addresses more extensive proximal humerus fractures. Proper code selection depends on precise fracture location documented in operative notes and imaging.

What modifiers are required when billing CPT 23630?

Laterality modifiers LT (left) or RT (right) are mandatory for CPT 23630 to indicate which shoulder was treated. Additional modifiers may include 22 (increased procedural services), 54 (surgical care only), 78 (return to OR for complication), 79 (unrelated procedure during postop period), or 80 (assistant surgeon) depending on specific case circumstances.

Does CPT 23630 have a global period?

Yes, CPT 23630 has a 90-day global surgical package. This means preoperative evaluation (typically 1 day before), the surgery itself, and all routine postoperative care for 90 days after the procedure are included in the single reimbursement. Any unrelated procedures during this period require modifier 79, while related returns to the OR require modifier 78.

What documentation is needed to support medical necessity for CPT 23630?

Medical necessity documentation should include pre-operative imaging with fracture displacement measurements (typically >5mm displacement justifies surgery), functional assessment showing shoulder dysfunction, failed conservative management when applicable, patient factors affecting healing (age, activity level, occupation), and clinical rationale for choosing open surgical fixation over closed treatment. Operative reports must detail fracture pattern, reduction technique, and fixation method to support the code assignment.