Summary & Overview
CPT 23195: Resection of Proximal Humeral Head for Infection or Tumor
CPT code 23195 denotes surgical removal of the rounded portion of the upper arm bone (humeral head) where it connects to the shoulder joint, performed for conditions such as osteomyelitis, necrotic bone, or tumor. This procedure is a focused orthopedic resection that can be performed in inpatient hospital operating rooms or ambulatory surgical centers depending on complexity and patient needs. Nationally, 23195 is relevant for surgeons, hospital billing departments, and payers because it represents a definitive surgical intervention for destructive or infectious processes affecting the proximal humerus and carries implications for facility and professional payment, authorization, and quality reporting.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication presents clinical context for the procedure, typical sites of service, and the billing parameters associated with 23195. Readers will learn operational benchmarks where available, common billing modifiers and claim practices (Data not available in the input), and policy considerations that affect coverage and coding for major upper-extremity resections.
The article summarizes clinical indications, expected care settings, and the administrative elements relevant to submitting and adjudicating claims for CPT code 23195, providing a concise reference for coders, clinicians, and payer policy analysts. Data not available in the input.
Billing Code Overview
CPT code 23195 describes a surgical procedure in which the rounded portion of the upper arm bone (humeral head) is removed where it connects to the shoulder joint. The procedure is performed to treat conditions such as osteomyelitis, necrotic bone, or tumor affecting the proximal humerus.
Service type: Surgical resection of proximal humerus (partial humeral head resection)
Typical site of service: Hospital operating room or ambulatory surgical center, depending on clinical complexity and patient status.
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Clinical & Coding Specifications
Clinical Context
A 62-year-old patient presents with chronic shoulder pain, progressive limitation of range of motion, fevers, and elevated inflammatory markers. Imaging (plain radiographs and MRI) demonstrates focal destruction of the humeral head with sequestrum suggestive of osteomyelitis; prior antibiotic therapy has been insufficient and there is concern for necrotic bone. The orthopedic surgeon schedules an operative debridement with resection of the humeral head (humeral head ostectomy) to remove infected and nonviable bone and to control local infection. The procedure is typically performed in an operating room under general or regional anesthesia. Preoperative workflow includes informed consent, cross-sectional imaging review, perioperative antibiotics, and coordination with anesthesia. Intraoperative steps include patient positioning (beach-chair or supine with arm support), surgical approach to the shoulder (deltopectoral or transdeltoid), exposure of the humeral head, resection of the rounded humeral head portion, irrigation and debridement, culture specimen collection, and possible placement of antibiotic cement spacer if staged reconstruction is planned. Postoperative workflow includes recovery in PACU, inpatient monitoring for infection control, continuation of directed antimicrobial therapy guided by intraoperative cultures, physical therapy as tolerated, and outpatient follow-up for wound checks and definitive reconstruction planning if indicated. Typical site of service is an inpatient hospital operating room or ambulatory surgery center when clinically appropriate; anesthesia services are billed separately. Common payors for authorization and claims include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.
Coding Specifications
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