CPT 23156 Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

CPT 23156: Excision/Curettage of Proximal Humerus Cyst with Bone Graft

CPT code 23156 denotes surgical curettage or excision of a benign cyst or noncancerous mass from the proximal humerus with placement of donor bone graft and submission of the specimen for laboratory analysis. This code captures a targeted orthopedic surgical procedure used to address structural defects and pathology in the upper humerus that require lesion removal and grafting. Nationally, accurate coding of these procedures affects hospital and ambulatory surgery center billing, case mix reporting, and postoperative quality tracking.

Key payers analyzed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for the procedure, guidance on typical sites of service, and a summary of common modifiers and operational considerations encountered in claims (Data not available in the input where payer-specific benchmarks would normally appear). The publication also outlines what to expect in documentation and coding workflows, including specimen submission for pathology and the role of bone grafting in defect reconstruction.

This resource is intended for coding professionals, billing managers, and clinical administrators seeking a national overview of CPT code 23156, its clinical indications, and the administrative elements that commonly accompany claims for proximal humerus cyst excision with grafting.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareCPT 23156orthopedic surgerybone graftingproximal humerussurgical excisionpathology submissionoperative codingmusculoskeletal

Billing Code Overview

CPT code 23156 describes surgical removal (curettage or excision) of a cyst or other benign lesion from the proximal humerus with placement of a donor bone graft and submission of the specimen for laboratory analysis. This procedure is an orthopedic oncologic/benign bone lesion procedure focused on eradication of a noncancerous mass in the upper humeral metaphysis or proximal humerus.

Service type: Surgical excision/curettage with bone grafting and tissue submission for pathology
Typical site of service: Hospital operating room or ambulatory surgical center (inpatient or outpatient surgical setting depending on clinical factors)

Clinical & Coding Specifications

Clinical Context

A 38-year-old otherwise healthy female presents with progressive, focal pain and a palpable fullness over the proximal aspect of the right upper arm. Imaging (radiographs and MRI) demonstrates a well-circumscribed, lytic, nonaggressive-appearing bone lesion in the proximal humerus consistent with a benign bone cyst or enchondroma. The orthopedic surgeon schedules an operative procedure for curettage of the lesion with allograft bone grafting to fill the resulting defect. Intraoperative steps include general anesthesia, a deltopectoral or lateral approach to the proximal humerus, exposure of the lesion, curettage and/or burring to remove cystic tissue, irrigation, packing the defect with donor (allograft) bone graft, and submission of tissue for pathology analysis. Postoperative care includes routine wound checks, pain control, immobilization in a sling for comfort, and radiographic follow-up to assess graft incorporation and rule out recurrence. Typical sites of service are an outpatient ambulatory surgery center or an inpatient hospital operating room depending on comorbidities, complexity, or payer requirements.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when reporting only the surgeon's professional service separate from a facility technical component (rare for this surgical code).

CPT 23180: Excision of Infected Bone, Proximal Humerus

CPT-23101-ACROMIOCLAVICULAR-STERNOCLAVICULAR-JOINT-DEBRIDEMENT-BIOPSY

CPT 23101: Acromioclavicular/Sternoclavicular Joint Debridement or Biopsy

CPT-23073-SHOULDER-INTRAMUSCULAR-MASS-EXCISION-5CM-OR-GREATER

CPT 23073: Excision of Intramuscular Shoulder Mass, Specimen ≥5 cm

CPT-23065-SHOULDER-SUPERFICIAL-SOFT-TISSUE-BIOPSY

CPT 23065: Superficial Soft Tissue Biopsy, Shoulder

CPT-23066-SHOULDER-DEEP-SOFT-TISSUE-EXCISIONAL-BIOPSY

CPT 23066: Excisional Biopsy of Deep Soft Tissue, Shoulder

CPT-23078-EXTENSIVE-EXCISION-SHOULDER-SOFT-TISSUE-SARCOMA-5CM-PLUS

CPT 23078: Extensive Excision of Shoulder Soft Tissue Malignant Tumor

CPT-23220-PROXIMAL-HUMERUS-TUMOR-RESECTION

CPT 23220: Radical Resection of Tumor, Proximal Humerus

CPT-23105-SHOULDER-SYNOVECTOMY-OPEN-ARTHROTOMY

CPT 23105: Open Shoulder Synovectomy with Synovial Excision

CPT-23155-HUMERUS-CYST-EXCISION-WITH-BONE-GRAFT

CPT 23155: Humerus Cyst Excision with Autologous Bone Graft

CPT-23190-SCAPULAR-PARTIAL-RESECTION-SHOULDER-BLADE-EXCISION

CPT 23190: Partial Resection of Scapula for Infection or Tumor

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Taxonomy Code	Specialty	Notes
`207X00000X`	Orthopaedic Surgery	Primary specialty performing bone lesion curettage and grafting of the proximal humerus.
`2080S0102X`	Orthopedic Hand Surgery	Hand/upper-extremity subspecialists who may manage proximal humerus pathology.
`2086S0102X`	Orthopaedic Oncology	Specialists who evaluate and treat complex or atypical bone lesions and coordinate pathology review.
`207L00000X`	Physical Medicine & Rehabilitation	Providers involved in postoperative rehabilitation and functional recovery planning.
`208U00000X`	General Surgery	Occasionally involved in bone lesion excision in multidisciplinary or resource-limited settings.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M85.8`	Other specified disorders of bone density and structure	May be used for atypical benign bone lesions requiring curettage and grafting.
`M85.9`	Disorder of bone, unspecified	Occasionally used when a more specific benign bone lesion code is not available but clinical presentation warrants surgical management.
`D16.9`	Benign neoplasm of bone, unspecified	Common diagnosis for benign bone tumors such as enchondroma when the site is the upper limb.
`M89.9`	Disorder of bone, unspecified	General code used when specific characterization of a nonmalignant bone lesion is pending pathology.
`S49.011A`	Complete traumatic fracture of proximal humerus, right, initial encounter for closed fracture	Included because curettage and grafting may be used for cystic defects related to prior fracture nonunion or bone loss.
`M84.35`	Stress fracture, right humerus	Included when curettage and grafting address focal bone weakness or lesion contributing to stress fracture.
`M85.4`	Cyst of bone	Directly relevant for simple bone cysts of the proximal humerus that are treated with curettage and grafting.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`20680`	Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate)	May be performed if prior hardware obstructs access to the proximal humerus lesion.
`20930`	Allograft, morselized, or placement of osteopromotive material, for spine or other surgical use (includes obtaining and preparing graft)	Related to grafting material; used when additional billing for specialized allograft product procedures is required (note: bundling rules vary).
`23130`	Excision, tumor, soft tissue of shoulder area; subcutaneous mass (less than or equal to 5 cm)	Performed for superficial soft-tissue masses of the shoulder region; may be performed in conjunction if soft-tissue involvement exists.
`27370`	Biopsy, bone, other than percutaneous; open (for femur, tibia, humerus)	Performed when an open bone biopsy is required prior to or at the time of definitive curettage to obtain diagnostic tissue.
`29827`	Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)	Represents arthroscopic shoulder procedures that may be performed concurrently if there is joint involvement requiring address during the same anesthetic.
`99024`	Postoperative follow-up visit, global period not included (routine postoperative follow-up)	Used by some payers for distinct postoperative evaluation beyond the global surgical package when allowed.

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