Surgical incision and drainage of an infected bursa in the shoulder joint

Verified May 8, 2026 · 4 sources ↓

Medicare: $464.94
Total RVUs: 13.92
Global, days: 10
Region: Shoulder

Drawn from CMSAAPC

Documentation requirements

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

Source · Editorial brief grounded in 4 cited references ↓

Confirmed infectious etiology — culture results, lab values, or clinical findings supporting septic bursitis
Specific bursa identified (subacromial, subdeltoid, or other) — vague anatomic references invite audit flags
Operative note documenting the incision, drainage of purulent material, and irrigation technique
Pre-op assessment establishing medical necessity for open I&D over aspiration alone
Post-op plan including wound care, antibiotic regimen, and follow-up timeline within the 10-day global

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 25 Significant separate E/M 51 Multiple procedures 58 Staged or related 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 4 cited references ↓

CPT 23031 covers open surgical incision and drainage of an infected shoulder bursa — one of the fluid-filled sacs that cushions the shoulder structures. The procedure is distinct from simple aspiration; it requires a formal operative approach to evacuate purulent material and address the infection source.

The code carries a 10-day global period. That covers the day of surgery plus routine follow-up through day 10. Any unrelated procedure performed during that window requires modifier 79. A related return to the OR for the same infection — say, repeat debridement — requires modifier 78.

Don't conflate 23031 with aspiration codes (20610 for shoulder joint/bursa aspiration). If you're draining an abscess rather than a discrete bursa, the distinction matters for ICD-10 linkage and medical necessity documentation. Infectious etiology must be explicit in the record — 'shoulder pain' as the sole diagnosis will trigger a medical necessity denial.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	2.72
Practice expense RVU	10.63
Malpractice RVU	0.57
Total RVU	13.92
Medicare national rate	$464.94
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	$464.94
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 23031 get rejected.

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

Medical necessity not established — diagnosis codes like M75.5 (bursitis) without infectious qualifier don't support I&D
Bundling with same-day aspiration code 20610 — payers view aspiration as integral to the I&D
Modifier missing when billed during another procedure's global period
ICD-10 mismatch — shoulder infection codes (M71.01x for infective bursitis) must align with the operative report findings

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 4 cited references ↓

01Can 23031 and 20610 be billed together on the same date?

No. Aspiration of the shoulder bursa is considered integral to the open I&D. Billing 20610 alongside 23031 on the same shoulder will trigger a bundling edit. Report 23031 only.

02What ICD-10 codes support 23031?

M71.01x (infective bursitis, shoulder) is the primary match. You need a laterality qualifier (M71.011 right, M71.012 left). If an organism is identified, add the causative organism code (e.g., B95.x for Staphylococcus). Avoid M75.5 alone — it doesn't convey infection.

03What modifier applies if the surgeon performs 23031 during the global period of a prior shoulder surgery?

Use modifier 79 if the infected bursa is unrelated to the prior procedure. Use modifier 78 if the I&D is a direct complication of or related to the original surgery. Inverting these modifiers is a common audit finding.

04Is 23031 appropriate for a subdeltoid versus subacromial bursa infection?

Yes — the code covers incision and drainage of any infected shoulder bursa. Document the specific bursa by name in the operative report. The distinction matters for clinical accuracy and audit defense, even though the CPT code is the same.

05How does the 10-day global period affect billing for a follow-up office visit?

Routine post-op visits within the 10-day global are included and cannot be billed separately. If the patient presents for a problem unrelated to the shoulder I&D, append modifier 24 to the E/M code and document the distinct medical reason clearly.

06Can modifier 22 be appended if the case was unusually complex?

Yes, but you need documentation to back it up — operative note must describe specific complexity factors (extensive debridement, multiloculated abscess, difficult anatomy, significantly prolonged operative time). Submit with a cover letter and operative note. Payers will deny or reduce without supporting documentation.

Sources & references

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

Mira AI Scribe

Mira's AI scribe captures the specific bursa involved, the nature of the drainage (purulent, serous-bloody), intraoperative culture collection, irrigation volume, and wound closure or packing method from your dictation. That detail directly supports the infectious ICD-10 linkage and medical necessity reviewers need — preventing the most common denial: a non-specific bursitis diagnosis paired with a surgical drainage code.

See how Mira captures CPT 23031 documentation