2025 CPT code 23035

Incision of the bone cortex in the shoulder area for conditions such as osteomyelitis or bone abscess.

This code is for incision and drainage of the bone cortex only. If other procedures are performed, such as extensive debridement of surrounding soft tissues, repair of tendons, or placement of hardware, they should be coded separately.

Modifiers may be applicable to this code. Modifier 54 Surgical Care Only and modifier 76 Repeat procedure or service by same physician might apply under certain scenarios.

Medical necessity must be supported by documentation indicating active infection in the shoulder bone, such as imaging findings, positive cultures, or clinical signs and symptoms of infection.

The physician or other qualified healthcare professional performs the procedure, including prepping the patient, making the incision, debriding the infected tissue, inserting a drainage tube, irrigating the area, and closing the incision.

In simple words: This procedure involves making a cut into the surface of the shoulder bone to treat a bone infection.The surgeon cleans out the infected area and may place a small tube to drain any remaining fluid.

This code describes a surgical incision into the outer layer of bone (cortex) in the shoulder area to address infections like osteomyelitis or a bone abscess.It involves making an incision, dissecting through muscle and fascia to reach the bone, and then debriding the infected tissue. A drainage tube may be inserted, and the area is typically irrigated with an antibiotic solution before closure.

Example 1: A patient presents with shoulder pain, fever, and localized swelling. Imaging reveals a bone abscess in the humerus.CPT code 23035 is used to report the incision and drainage of the abscess., A patient with a history of open shoulder fracture develops signs of osteomyelitis. The surgeon performs an incision into the affected bone to remove the infected tissue, and code 23035 is reported., A diabetic patient develops a deep bone infection in the clavicle.The surgeon performs a surgical incision to access the infected bone, debride the area, and insert a drainage tube. This procedure is reported with code 23035.

Documentation should include details of the patient's presentation, imaging findings confirming the diagnosis (e.g., osteomyelitis, bone abscess), operative report detailing the procedure performed, including the location and extent of the incision, debridement, and drainage tube placement if applicable.

  • Specialties:Orthopedic Surgery
  • Place of Service:"Inpatient Hospital", "Ambulatory Surgical Center", "Outpatient Hospital"
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