Summary & Overview

CPT 23076: Excision of Intramuscular Shoulder Mass, <5 cm

CPT code 23076 represents the surgical excision of an intramuscular mass or tumor in the shoulder, with the specimen being less than 5 cm including margins and submitted for pathological analysis. This code captures a targeted operative procedure on deep soft tissue of the shoulder that has implications for surgical coding, pathology processing, and postoperative care. Nationally, accurate use of this code affects surgical case reporting, quality measurement, and appropriate reimbursement for soft-tissue tumor management.

Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of coding intent, typical clinical and site-of-service context, common modifiers associated with surgical procedures, and where to look for related documentation requirements. The publication also outlines benchmarking elements and policy considerations relevant to payers and providers, including coverage alignment for surgical excision, specimen submission for pathology, and coding nuances tied to lesion size and anatomic specificity.

This summary is intended to give clinicians, coders, and policy analysts a clear, national-level orientation to CPT code 23076, what it denotes clinically, and the practical points that commonly influence claim adjudication and clinical documentation.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareCPT 23076shoulder surgerysoft tissue excisionsurgical pathologyorthopedicsprocedural codingambulatory surgeryhospital outpatient

Billing Code Overview

CPT code 23076 describes the excision of an abnormal mass or tumor located within the intramuscular tissue of the shoulder. The procedure includes removal of the lesion and submission of the specimen, less than 5 cm including margins, to a laboratory for analysis and diagnosis.

Service type: Surgical excision of intramuscular shoulder mass
Typical site of service: Hospital operating room or ambulatory surgical center

Clinical & Coding Specifications

Clinical Context

A 52-year-old patient presents to the orthopedic clinic with a progressively enlarging, palpable mass deep within the deltoid region of the right shoulder associated with intermittent pain and limited range of motion. Preoperative evaluation includes history and physical, shoulder radiographs and MRI to localize the intramuscular lesion and to estimate size. The patient is scheduled for an excision of an intramuscular shoulder mass under general anesthesia in an ambulatory surgery center or hospital outpatient department. Intraoperative workflow includes incision, dissection through subcutaneous tissue and muscle to the lesion, en bloc excision of the mass with gross margins, hemostasis, wound closure, and submission of the specimen less than 5 cm in greatest dimension to the pathology laboratory for gross and microscopic analysis. Postoperative management includes standard PACU recovery, wound care instructions, and follow-up for pathology results and further oncologic or orthopedic management as indicated.

Coding Specifications

Modifier	Description	When to Use
`LT`	Left side	Use when procedure performed on the left shoulder.
`RT`	Right side	Use when procedure performed on the right shoulder.
`50`	Bilateral procedure	Use when both shoulders are operated on during the same operative session.
`59`	Distinct procedural service	Use when a separate, distinct procedure unrelated to the excision is performed at the same encounter.
`26`	Professional component	Use if only the professional component of an associated diagnostic service is billed (rare for excision CPT).
`TC`	Technical component	Use if only the facility/technical component of an associated diagnostic service is billed.
`22`	Increased procedural services	Use when work required is substantially greater than typical for excision due to complexity.
`52`	Reduced services	Use when the service performed is reduced or incomplete.
`53`	Discontinued procedure	Use when the procedure is started but discontinued due to unforeseen circumstances.
`76`	Repeat procedure by same physician (note: not in provided list)	Data not available in the input.
`73`	Discontinued outpatient hospital/ambulatory surgery before anesthesia administered	Use when surgery is cancelled after preparation but before anesthesia (applicable in facility billing).
`78`	Unplanned return to OR by same physician following initial procedure for a related procedure during the postoperative period	Use for re-operation related to complications.
`79`	Unrelated procedure or service by the same physician during the postoperative period	Use when an unrelated procedure is performed during global period.
`58`	Staged or related procedure or service by the same physician during the postoperative period	Use when a planned subsequent procedure is performed during the postoperative period.

Taxonomy Code	Specialty	Notes
`207X00000X`	Orthopaedic Surgery	Orthopedic surgeons commonly perform intramuscular shoulder mass excisions.
`208100000X`	General Surgery	General surgeons may perform soft tissue mass excisions depending on setting and expertise.
`208V00000X`	Plastic Surgery	Plastic surgeons may perform excisions when reconstruction or complex closure is anticipated.
`363E00000X`	Pathology	Pathologists receive and analyze excised specimens; included as associated specialty.
`208600000X`	Hand Surgery	Upper extremity–focused surgeons may perform shoulder soft tissue mass excision when expertise overlaps.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M79.1`	Myalgia	May be listed when shoulder pain prompts imaging that discovers an intramuscular mass.
`M75.10`	Unspecified rotator cuff tear or tendinitis of unspecified shoulder	Included when concomitant shoulder pathology is present that contributed to symptoms prompting evaluation.
`D21.9`	Benign neoplasm of connective and other soft tissue, unspecified site	Common diagnosis when pathology shows a benign soft tissue tumor such as lipoma or fibroma.
`C49.A9`	Malignant neoplasm of connective and soft tissue of unspecified upper limb, including shoulder	Used when pathology confirms a malignant soft tissue sarcoma in the shoulder region.
`M79.89`	Other specified soft tissue disorders, not elsewhere classified	Used for non-specific soft tissue masses or disorders prompting excision.
`S46.011A`	Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter	May coexist or be a differential when shoulder pain is present; relevant to operative planning.
`R22.31`	Localized swelling, mass and lump, right upper limb	Symptom code often used when a palpable shoulder/upper arm mass is the presenting complaint.
`M75.00`	Adhesive capsulitis of unspecified shoulder	Included when shoulder stiffness is part of the clinical picture leading to evaluation and imaging that detects a mass.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`23075`	Excision of lesion of intramuscular soft tissue, shoulder area; 5 cm or greater	Used when the excised specimen measures 5 cm or larger; provides correct sizing-based code selection relative to `23076`.
`24075`	Excision of lesion of bone, shoulder; biopsy or excision, benign or malignant	Performed when the lesion involves bone rather than intramuscular soft tissue; may be part of differential surgical management.
`11042`	Debridement; subcutaneous tissue (eg, for wound debridement)	May be used if additional debridement of surrounding soft tissue is required during the procedure.
`20220`	Incision and drainage of deep abscess or hematoma of neck (example of drainage codes)	Data not available in the input.
`88305`	Level IV surgical pathology, gross and microscopic examination	Routinely used by pathology to report histologic examination of excised soft tissue mass specimens such as those delivered from `23076`.