CPT® Code 23030

An incision and drainage procedure for a deep abscess or hematoma in the shoulder area involves a surgical intervention aimed at alleviating the accumulation of pus or blood within the soft tissues surrounding the shoulder. The shoulder area encompasses the anatomical regions overlying the clavicle, scapula, and the humeral head and neck. The specific approach taken during the procedure is determined by the precise location of the abscess or hematoma. During the procedure, the surgeon dissects the soft tissues to locate the pocket of pus or blood. Once identified, the wall of the abscess or hematoma is incised to allow for the drainage of the accumulated fluid. In cases where a large abscess is present, additional probing may be necessary to break down loculations, ensuring that all infected material is effectively drained. Following the drainage, the site is typically flushed with an antibiotic solution and/or normal saline to reduce the risk of infection. Depending on the clinical situation, the abscess or hematoma site may be left open for continued drainage, packed with gauze to facilitate healing, or closed surgically. It is important to note that this procedure is distinct from the incision and drainage of an infected bursa, which is described under CPT® Code 23031, where the bursal sac is incised and the fluid is similarly drained and flushed.