CPT 23680Surgery

Optx sho dislc neck fx fixj

CPT 23680 covers surgery to repair a dislocated shoulder that also has a fracture of the anatomical neck of the humerus (upper arm bone), using internal fixation devices like plates or screws to stabilize the broken bone.

Showing rates for

National Average

Base Medicare rate

$920.26

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

13.15

PE RVU (NF)

12.63

MP RVU

2.67

Total RVU

28.45

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

NCCI bundling edits

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Billing tips

Always append RT or LT modifier for laterality - this is a CMS requirement for all bilateral procedures
Impact: Claims without laterality modifiers will auto-deny, delaying payment by 30-45 days on average
Document bone quality, fracture pattern (comminution level), soft tissue injury extent, and hardware specifications to support modifier 22 claims
Impact: Successful modifier 22 appeals can increase reimbursement by $184-$276 (20-30% increase)
Bill implants separately using hospital UB-04 revenue codes or ASC implant pass-through billing; surgeon professional fee does not include device costs
Impact: Implant costs typically add $2,000-$5,000 in facility reimbursement beyond the $920.26 professional fee
Verify that the fracture is specifically at the anatomical neck; surgical neck fractures use different codes (23615, 23616) and will be denied if miscoded
Impact: Coding errors between 23680 and 23615/23616 result in denials requiring complete claim resubmission
For trauma cases, link appropriate diagnosis codes for both dislocation (S43.004A-S43.006A) and fracture (S42.291A-S42.296A) with seventh character 'A' for initial encounter
Impact: Missing or incorrect seventh character extensions cause automatic claim rejections at clearinghouse level
When performed in ASC setting, verify payer coverage as some plans require hospital setting for this complexity level
Impact: ASC setting denial requires complete rebilling and may reduce reimbursement by 15-20% even after appeal

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23680 in 2025?

The 2025 Medicare national average payment for CPT 23680 is $920.26 for both facility and non-facility settings, based on 28.45 total RVUs and a conversion factor of 32.3465.

What is the difference between CPT 23680 and 23615?

CPT 23680 is for open treatment of shoulder dislocation with anatomical neck fracture requiring fixation, while 23615 is for open treatment of proximal humeral (surgical neck) fracture without dislocation. The key differences are the presence of dislocation and the specific fracture location (anatomical vs. surgical neck).

How many RVUs does CPT code 23680 have?

CPT 23680 has 28.45 total RVUs for 2025, consisting of 13.15 work RVUs, 12.63 practice expense RVUs, and 2.67 malpractice RVUs.

Can CPT 23680 be billed bilaterally?

While technically possible to have bilateral injuries requiring this procedure, it would be extremely rare. If both shoulders require this surgery, bill each side separately with RT and LT modifiers and modifier 50 for bilateral procedure if payer requires, though most payers prefer separate line items with laterality modifiers.

What diagnosis codes are appropriate for CPT 23680?

Appropriate ICD-10 codes include S42.291A-S42.296A for unspecified fracture of anatomical neck of humerus (with laterality and initial encounter) paired with S43.004A-S43.006A for unspecified dislocation of shoulder joint to document both components of the injury.

Is CPT 23680 covered in an ASC setting?

Coverage varies by payer. Medicare assigns the same facility rate ($920.26) for ASC and hospital outpatient settings, but some commercial payers may require hospital setting due to complexity. Verify coverage before scheduling to avoid denials.

What modifiers are required when billing CPT 23680?

Laterality modifiers RT (right) or LT (left) are mandatory for CPT 23680. Additional modifiers such as 22 (increased complexity), 62 (co-surgeons), 80 (assistant surgeon), or 54/55 (split care) may be appropriate based on specific circumstances of the case.