CPT® Code 23031

An incision and drainage procedure of the shoulder area, specifically for an infected bursa, involves the surgical intervention to remove infected fluid or pus from the bursal sac located in the shoulder region. The shoulder area encompasses the soft tissues overlying critical anatomical structures such as the clavicle, scapula, and the humeral head and neck. The procedure is initiated based on the precise location of the abscess or hematoma, which may be deep within the shoulder tissues. During the operation, the surgeon carefully dissects the soft tissues to access the infected area, where the abscess or hematoma is identified. The wall of the abscess is then incised to allow for the drainage of the accumulated pus or blood. In cases where a large abscess is present, additional probing may be necessary to break down loculations within the pus pocket, ensuring complete drainage of the infection. Following the drainage, the site is typically flushed with an antibiotic solution and/or normal saline to cleanse the area. Depending on the clinical judgment, the incision may be left open for continued drainage, packed with gauze to facilitate healing, or closed after thorough irrigation. This procedure is specifically coded as CPT® 23031, which denotes the incision and drainage of an infected bursa in the shoulder area.