2025 CPT code 23030
Effective Date: N/A Surgery - Musculoskeletal System Feed
Incision and drainage of a deep abscess or hematoma in the shoulder area.
Modifiers are applicable to this code. Refer to the provided source for potential modifiers, such as 22 (Increased Procedural Services), 50 (Bilateral Procedure), 54 (Surgical Care Only), etc.
Medical necessity is established by the presence of a deep abscess or hematoma in the shoulder area causing pain, limiting function, or posing a risk of infection spread.
The physician prepares the patient, administers anesthesia, makes the incision, drains the fluid, may obtain a specimen for analysis, irrigates the area, controls bleeding, and closes the incision.
In simple words: The doctor will make a cut in your shoulder area to drain a deep pocket of infection or blood. This will help relieve pain and pressure and/or treat the infection.
Incision and drainage, shoulder area; deep abscess or hematoma.This code describes a surgical procedure where an incision is made to drain a deep collection of pus (abscess) or blood (hematoma) located within the shoulder area.It involves dissecting down to the deep fascia to access and drain the fluid. The procedure typically includes irrigation of the affected area and may involve submitting a specimen for laboratory analysis.
Example 1: A patient presents with a deep abscess in the deltoid muscle.The physician performs an incision and drainage using code 23030., Following a shoulder injury, a patient develops a deep hematoma. The physician performs an incision and drainage using code 23030., A patient with a history of intravenous drug use presents with a deep shoulder abscess.The physician performs an incision and drainage using code 23030 and sends a sample of the drained fluid for culture and sensitivity testing.
Documentation should include details of the location and depth of the abscess/hematoma, the procedure performed (incision and drainage), any associated findings (e.g., purulent material, blood), and any specimens sent for analysis.
- Revenue Code: P5B
- Global Days : 10
- Specialties:Orthopedic Surgery, General Surgery
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Ambulatory Surgical Center