2025 CPT code 23031
Effective Date: N/A Surgery - Surgical Procedures on the Musculoskeletal System Feed
Incision and drainage of infected bursa in the shoulder area.
Modifiers may be applicable to code 23031 to indicate specific circumstances, such as increased procedural services (22), bilateral procedures (50), or repeat procedures by the same physician (76) or another physician (77).The appropriateness of modifier use is dependent on the specific payer guidelines and the circumstances of the procedure.
Medical necessity for 23031 is established when an infected bursa in the shoulder requires drainage to resolve the infection and prevent its spread.This may be indicated by signs of infection such as pain, swelling, redness, warmth, and fever.Conservative treatments may be attempted prior to surgical intervention.
The physician prepares the patient, provides anesthesia, makes an incision, drains the bursa, may obtain a specimen for analysis, irrigates the area, controls bleeding, and closes the incision.
In simple words: The doctor will make a small cut in your shoulder to drain the infected fluid from the bursa. The bursa is a small sac of fluid that helps cushion the joint. This procedure helps treat the infection and reduce pain and swelling.
Incision and drainage of the shoulder area for an infected bursa.The procedure involves making an incision, draining the infected fluid, and irrigating the bursa with antibiotics.
Example 1: A patient presents with a swollen, painful, and red shoulder due to an infected subacromial bursa. The physician performs an incision and drainage to remove the infected fluid and alleviate the symptoms., A patient with a history of recurrent shoulder pain and swelling is diagnosed with septic bursitis. Incision and drainage is performed to address the infection and prevent complications., Following a shoulder injury, a patient develops an infection in the subdeltoid bursa.The physician performs an incision and drainage procedure to clear the infection.
Documentation should include the location of the infected bursa, signs and symptoms of infection (e.g., swelling, redness, pain, fever), and any cultures taken. Operative details including size and location of incision, amount and character of drainage, and method of irrigation should also be documented.
- Specialties:Orthopedic Surgery, Sports Medicine
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Ambulatory Surgical Center