CPT 23935Surgery

Inc dp opn b1 crtx hum/elbw

CPT code 23935 covers a surgical procedure where a physician makes an incision to remove a sample of bone tissue from the upper arm (humerus) or elbow area for diagnostic testing. This is a deep open biopsy performed in an operating room, not a simple needle biopsy.

Showing rates for

National Average

Base Medicare rate

$513.34

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

6.38

PE RVU (NF)

8.22

MP RVU

1.27

Total RVU

15.87

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

NCCI bundling edits

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Billing tips

Always append laterality modifiers (LT/RT) even though the code descriptor does not explicitly require it - many Medicare contractors auto-deny without laterality
Impact: Prevents automatic denials that delay payment by 30-60 days and require resubmission
Document the specific depth of dissection and cortical bone access in the operative report - use terms like 'cortical bone' and 'deep dissection through muscle' to differentiate from superficial procedures
Impact: Prevents downcoding to 20220 (bone biopsy, trocar or needle) which reimburses only $99.97, resulting in $413.37 loss
Submit pathology report with initial claim submission when possible, especially for payer pre-authorization or when medical necessity may be questioned
Impact: Reduces denial rate by approximately 15-20% and eliminates appeals process that costs $25-40 in administrative time per claim
When performed with another procedure, ensure documentation clearly separates the biopsy from the primary procedure with distinct operative notes for each service
Impact: Protects full $513.34 reimbursement when modifier 59 is applied; bundled claims lose entire biopsy payment
Verify facility vs non-facility place of service coding matches actual location - both reimburse identically at $513.34 but incorrect POS codes trigger audits
Impact: Prevents payment recoupment during post-payment audits which can freeze future payments until resolved
Link appropriate ICD-10 diagnosis codes that support medical necessity (pathological fracture, bone lesion, suspected malignancy) - avoid using screening or symptom-only codes

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 23935 in 2025?

The 2025 Medicare national average reimbursement for CPT 23935 is $513.34 for both facility and non-facility settings. This is based on 15.87 total RVUs (6.38 work RVU, 8.22 PE RVU, 1.27 MP RVU) multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary based on geographic location and GPCI adjustments.

What is the difference between CPT 23935 and CPT 20220?

CPT 23935 is specifically for deep open incisional biopsy of the cortical bone of the humerus or elbow, requiring surgical dissection through soft tissue to access bone. CPT 20220 is for percutaneous needle or trocar bone biopsy that can be performed anywhere in the musculoskeletal system with minimal incision. The key differentiator is the surgical approach: 23935 requires open visualization and access to cortical bone, while 20220 uses a needle/trocar through skin puncture.

Can CPT 23935 be billed with an E/M code on the same day?

Yes, but only with modifier 25 appended to the E/M code if a separately identifiable evaluation and management service is performed beyond the standard pre-operative assessment. The E/M must be for a significant, separately identifiable service such as evaluation of another condition or a new problem. Routine pre-operative assessment is included in the surgical package and cannot be separately billed.

What diagnosis codes support medical necessity for CPT 23935?

Diagnosis codes that typically support medical necessity include: bone lesions (D16.-, D48.0), suspected bone malignancy (C40.-, C41.-), chronic osteomyelitis (M86.-), pathological fracture (M84.4-), bone pain with abnormal imaging (M25.5- plus abnormal imaging findings), and metabolic bone disease requiring tissue diagnosis (M80.-, M81.-). Generic symptom codes without imaging abnormalities are frequently denied.

Is CPT 23935 performed in outpatient or inpatient settings?

CPT 23935 can be performed in either outpatient or inpatient settings depending on patient medical complexity and clinical circumstances. The Medicare reimbursement is identical ($513.34) regardless of setting. Most cases are performed in hospital outpatient departments or ambulatory surgery centers, but inpatient admission may be necessary for patients with significant comorbidities, bleeding disorders, or when performed in conjunction with other inpatient procedures.

How many RVUs is CPT code 23935 worth?

CPT 23935 has a total of 15.87 RVUs for 2025, consisting of 6.38 work RVUs (physician time and intensity), 8.22 practice expense RVUs (both facility and non-facility), and 1.27 malpractice RVUs. This moderate RVU value reflects the surgical complexity and time required for open bone biopsy compared to percutaneous techniques.

What modifiers are most commonly used with CPT 23935?

The most commonly used modifiers are LT/RT (laterality - left or right), modifier 59 (distinct procedural service when performed with another procedure), modifier 22 (increased procedural services for unusual complexity), and modifier 50 (bilateral procedure if both sides are biopsied). Laterality modifiers are essential even though not explicitly required by the code descriptor, as many payers auto-deny without them.