Surgical incision and drainage of a deep abscess or hematoma located in the shoulder area, requiring dissection through soft tissue to reach and evacuate the fluid collection.

Verified May 8, 2026 · 7 sources ↓

Medicare: $473.96
Total RVUs: 14.19
Global, days: 10
Region: Shoulder

Drawn from CMSAAPCAbosMdclarityNethealth

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 7 cited references ↓

Confirm dissection depth — explicitly state the collection was deep to subcutaneous tissue, not superficial
Specify the nature of the fluid evacuated (purulent material, hematoma, serous fluid) to support medical necessity
Document the anatomical location within the shoulder region (deltoid, subacromial space, axilla, etc.)
Record pre-op imaging or clinical findings that identified the deep collection and guided surgical planning
Note any irrigation, packing, drain placement, or wound closure technique used after drainage
Distinguish from infected bursa drainage (23031) or glenohumeral joint arthrotomy (23040) if either was considered

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 59 Distinct service 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

23030 covers open incision and drainage of a deep-seated abscess or hematoma in the shoulder region — not superficial skin I&D, not infected bursa (that's 23031), and not joint involvement (that's 23040). The procedure requires dissection through subcutaneous tissue and deeper soft tissue planes to reach the fluid pocket, establish drainage, and irrigate the cavity. Because the depth distinguishes this code from simpler shoulder skin procedures, the operative note must clearly document the dissection depth and confirm the collection was deep to subcutaneous tissue.

The global period is 010, meaning 10 post-op days of routine follow-up are included. Any E/M visits within those 10 days for unrelated problems need modifier 24. If wound care escalates beyond routine dressing changes within the global window, document medical necessity clearly — payers will bundle routine post-op management without it.

Site-of-service matters here: HOPD and ASC payment rates differ substantially (see the Site of Service comparison table). If you're performing this in the office, check whether your payer's fee schedule covers the office setting for this code or defaults to the facility rate.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	3.38
Practice expense RVU	10.11
Malpractice RVU	0.7
Total RVU	14.19
Medicare national rate	$473.96
Global period	10 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$473.96
HOPD (APC 5073) Hospital outpatient department	$2,967.63
ASC (PI A2) Ambulatory surgical center (freestanding)	$1,248.36

Common denial reasons

The recurring reasons claims for CPT 23030 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Depth not documented — payer downcodes to a superficial I&D when the note doesn't explicitly confirm deep dissection
Bundling with same-day shoulder arthroscopy or other shoulder procedure without modifier 59 to establish distinct service
ICD-10 mismatch — diagnosis codes for superficial abscess or skin abscess rather than deep soft tissue or intramuscular abscess
Missing laterality — claim submitted without LT or RT modifier when payer requires it for shoulder procedures
Debridement intent documented instead of drainage intent — if note language emphasizes tissue removal over fluid evacuation, payer may deny or request code swap

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01What separates 23030 from 23031?

23030 is for a deep abscess or hematoma in the soft tissue of the shoulder. 23031 is specifically for an infected bursa. If you're draining the subacromial or subdeltoid bursa due to infection, 23031 is correct. Document the anatomical source clearly — auditors look for this distinction.

02Can I bill 23030 and 23040 together if I also opened the joint?

Only if both procedures were genuinely distinct and separately documented. Append modifier 59 to the secondary code and make sure the operative note clearly describes two separate surgical interventions — one into deep soft tissue and one into the glenohumeral joint. Bundling is likely without that documentation.

03What ICD-10 codes pair with 23030?

Deep soft tissue abscess (L02.419 or site-specific equivalents), intramuscular abscess, and hematoma of the shoulder (M79.622 or trauma-specific codes like S40.012A) are the typical pairings. Avoid skin abscess codes — they signal superficial depth and invite downcoding.

04Does the 010 global period affect same-day E/M billing?

Yes. A same-day E/M that led to the decision to perform 23030 needs modifier 25 on the E/M to be separately payable. Within the 10-day global, E/M visits for unrelated problems require modifier 24. Routine wound checks in that window are bundled.

05When is modifier 22 appropriate for 23030?

Use modifier 22 when the drainage required substantially more work than typical — for example, a multiloculated deep abscess requiring extensive blunt dissection, or a large organizing hematoma with significant adhesions. The operative note must describe the specific factors that elevated the complexity. Don't append 22 without that documentation.

06Is modifier 50 ever valid for bilateral shoulder I&D on the same day?

Technically yes, but bilateral deep shoulder abscesses presenting simultaneously are clinically uncommon. If it occurs, document both sides in the operative note, append modifier 50, and expect payer scrutiny. Some payers require separate line items with LT and RT instead of modifier 50 — verify your payer's preference.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures dissection depth, fluid character (purulent vs. hematoma), and the specific shoulder compartment entered from your dictation. It flags operative notes that rely on generic language like 'deep tissue drained' without naming the anatomical layer — the type of vague documentation that triggers downcoding audits or depth-related denials on 23030.

See how Mira captures CPT 23030 documentation