Summary & Overview
CPT 23030: Incision and Drainage of Deep Shoulder Abscess or Hematoma
CPT code 23030 represents an operative incision and drainage (I&D) of a deep pocket of infection or blood in the shoulder. This procedure addresses deep-seated abscesses or hematomas that cause pain, pressure, or systemic infection risk and typically requires surgical intervention in an operating room, ambulatory surgical center, or inpatient setting depending on severity. Nationally, this code is relevant for emergency and orthopedic surgical services and influences facility and physician billing workflows for acute shoulder infections.
Key payers in this publication include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for CPT code 23030, typical sites of service, and the common modifiers used with the code. The publication outlines expected documentation elements, billing scenarios where the code applies, and how payers commonly classify the service for coverage and payment. It also provides benchmarks for utilization and payer policy highlights where available, plus practical notes on coding specificity and encounter settings.
Intended for coding professionals, surgical providers, and revenue cycle staff, the summary equips readers to recognize appropriate clinical indications for CPT code 23030, understand payer considerations, and locate policy and billing guidance relevant to deep shoulder incision and drainage procedures.
Billing Code Overview
CPT code 23030 describes an incision and drainage procedure for a deep pocket of infection or accumulated blood in the shoulder region. The service involves surgical opening, evacuation of purulent material or hematoma, and any necessary debridement to relieve pain, reduce pressure, and treat infection.
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Service type: Surgical, incision and drainage of deep shoulder space
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Typical site of service: Operative suite, ambulatory surgical center, or hospital inpatient/observation setting depending on clinical severity and patient needs
Clinical & Coding Specifications
Clinical Context
A 54-year-old male presents to the emergency department with acute onset severe right shoulder pain, fever, and progressive swelling after an episode of blunt trauma to the shoulder two days prior. Physical exam shows localized fluctuance deep to the deltoid with limited active range of motion and systemic signs of infection (fever, elevated white blood cell count). Imaging (ultrasound or MRI) identifies a deep intramuscular abscess or hematoma within the subacromial/subdeltoid or deep shoulder compartment. The orthopedic surgeon or general surgeon performs 23030 (incision and drainage of deep abscess or hematoma, shoulder) in the operating room under regional or general anesthesia to evacuate purulent material or blood, decompress the compartment, place a drain if needed, and obtain cultures. Post-procedure workflow includes wound culture results, targeted intravenous antibiotics, wound care with possible repeat irrigation and debridement if persistent infection, documentation of pre- and post-anesthesia findings, informed consent, operative note specifying approach and findings, and accurate coding with appropriate modifiers to reflect laterality, anesthesia, professional component, or complications.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
LT | Left side | Use when procedure performed on the left shoulder |