How To Use CPT Code 23030

CPT code 23030 describes the procedure of incision and drainage for a deep abscess or hematoma in the shoulder area. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 23030?

CPT 23030 is a code used to describe the incision and drainage procedure for a deep abscess or hematoma in the shoulder area. This procedure is performed to relieve pain and pressure, as well as to treat any infection present. It involves making a midline incision over the abscess, draining the fluid, and irrigating the area with antibiotics. The incision is then closed after ensuring there is no bleeding or remaining instruments.

2. Official Description

The official description of CPT code 23030 is: ‘Incision and drainage, shoulder area deep abscess or hematoma.’

3. Procedure

The procedure for CPT code 23030 involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. A midline incision is made over the abscess or hematoma.
3. The provider dissects down to the deep fascia.
4. The fluid is drained from the abscess or hematoma.
5. A specimen may be submitted to a laboratory for analysis.
6. The area is irrigated with antibiotics.
7. Bleeding is checked and controlled if necessary.
8. Any instruments used are removed.
9. The incision is closed.

4. Qualifying circumstances

CPT 23030 is performed on patients with a deep abscess or hematoma in the shoulder area. An abscess is a collection of pus in a walled-off sac or pocket, usually caused by infection. A hematoma, on the other hand, is a collection of blood or blood clot in the tissues, often resulting from damage to blood vessels. The procedure is typically performed by a healthcare professional who is qualified to perform incisions and drainage procedures.

5. When to use CPT code 23030

CPT code 23030 should be used when a healthcare professional performs an incision and drainage procedure for a deep abscess or hematoma in the shoulder area. It is important to note that this code is not appropriate if the procedure involves debridement in addition to drainage. Debridement involves the removal of damaged or unhealthy tissue and should be reported separately if performed.

6. Documentation requirements

To support a claim for CPT 23030, the healthcare professional must document the following information:

• Patient’s diagnosis of a deep abscess or hematoma in the shoulder area
• Details of the procedure, including the incision, drainage, and irrigation
• Any specimens submitted to a laboratory for analysis
• Documentation of bleeding control, instrument removal, and closure of the incision

7. Billing guidelines

When billing for CPT 23030, ensure that the procedure meets the criteria for this code, including the location (shoulder area) and the nature of the condition (deep abscess or hematoma). It is important to review the operative note to determine if any debridement was performed in addition to the drainage. If debridement is documented, separate codes for debridement should be reported. It is also essential to follow any specific guidelines provided by the payer regarding the use of modifiers or additional documentation requirements.

8. Historical information

CPT 23030 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient presents with a deep abscess in the shoulder area. The healthcare professional performs an incision and drainage procedure, relieving the patient’s pain and pressure.
2. An individual sustains a hematoma in the shoulder area due to trauma. The healthcare professional performs an incision and drainage procedure to remove the blood clot and alleviate discomfort.
3. A patient develops an infected abscess in the shoulder area. The healthcare professional performs an incision and drainage procedure, treating the infection and promoting healing.
4. An individual undergoes surgery in the shoulder area and subsequently develops a deep abscess. The healthcare professional performs an incision and drainage procedure to address the infection and prevent further complications.
5. A patient with a history of shoulder injuries presents with a deep abscess. The healthcare professional performs an incision and drainage procedure, providing relief and promoting healing.