Summary & Overview
CPT 23031: Incision and Drainage of Infected Shoulder Bursa
CPT code 23031 represents the surgical incision and drainage of an infected shoulder bursa. This procedure is performed to evacuate purulent material and decrease pain and pressure from bursitis with infection. Nationally, accurate coding and documentation for this code affect quality reporting, payment adjudication, and clinical records for musculoskeletal and infectious care.
Key payers commonly involved in coverage decisions include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical context for the procedure, typical sites of service, and the coding elements that drive billing recognition. The publication summarizes benchmark payment constructs, common modifier usage where relevant, and typical clinical indications tied to the code. It also highlights billing nuances that influence claim acceptance and coding audits.
The article is intended for clinicians, coding professionals, and revenue cycle staff seeking a concise reference on CPT code 23031, including how the procedure is described, where it is commonly performed, and what to expect in payer interactions and documentation requirements. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 23031 describes the incision and drainage of an infected bursa in the shoulder. The procedure involves making an incision to evacuate pus and inflammatory fluid from a bursae to treat infection and relieve pain and pressure.
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Service type: Surgical procedure for infection management
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Typical site of service: Ambulatory surgical center or hospital operating room; may also be performed in an urgent care or emergency department setting when clinically indicated
Clinical & Coding Specifications
Clinical Context
A 58-year-old patient presents to the outpatient orthopedic clinic with a 5-day history of progressive right shoulder pain, swelling, erythema, and fluctuance over the subacromial region. The patient reports fever and difficulty elevating the arm. On exam there is localized tenderness and a palpable fluctuant bursal swelling consistent with an infected subacromial bursa. Point-of-care ultrasound confirms a fluid collection within the subacromial-subdeltoid bursa. The provider discusses risks, obtains informed consent, prepares sterile field, administers local anesthesia, and performs an incision and drainage of the infected bursa, evacuating purulent fluid and obtaining specimens for Gram stain, culture and sensitivity. Hemostasis is achieved, wound is packed or dressed according to surgeon preference, and post-procedure instructions and antibiotics are provided. Typical site of service is an ambulatory surgery center or outpatient procedure room; inpatient OR may be used for complex cases or if concurrent procedures are required. Service type: minor surgical procedure — incision and drainage of an infected shoulder bursa, corresponding to 23031.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
52 | Reduced services | Use when the procedure is partially reduced or not completed as originally planned |