Overview of CPT Code 23000: Excision of shoulder bursa
CPT Code 23000 refers to the surgical procedure for the excision of the shoulder bursa, a fluid-filled sac that reduces friction between tissues in the shoulder joint. This procedure is typically performed to alleviate pain and improve shoulder function.
When CPT Code 23000 is Used?
This procedure is indicated in several clinical scenarios.
- Persistent shoulder pain not relieved by conservative treatments.
- Diagnosis of bursitis confirmed through imaging.
- Limited range of motion due to bursal inflammation.
- Presence of calcific deposits in the bursa.
- Recurrent shoulder impingement syndrome.
Symptoms Indicating This Procedure
Patients may report various symptoms that lead to the consideration of this procedure.
- Chronic shoulder pain, especially during movement.
- Swelling or tenderness over the shoulder.
- Stiffness or reduced range of motion.
- Pain radiating down the arm.
- Difficulty performing daily activities involving the shoulder.
Causes and Risk Factors
Understanding the underlying causes and risk factors is crucial for prevention.
- Repetitive overhead activities or sports.
- Age-related degeneration of shoulder structures.
- Previous shoulder injuries or surgeries.
- Inflammatory conditions such as rheumatoid arthritis.
- Obesity, which can increase joint stress.
Diagnostic Tests Before Procedure
Several diagnostic tests may be performed to confirm the need for this procedure.
- X-rays to rule out fractures or bone spurs.
- MRI to assess soft tissue structures and inflammation.
- Ultrasound to visualize the bursa and surrounding tissues.
- Blood tests to check for inflammatory markers.
Procedure Description
The excision of the shoulder bursa involves several key steps.
- Patient is positioned comfortably, usually in a sitting or lying position.
- Anesthesia is administered to ensure comfort during the procedure.
- An incision is made over the affected area of the shoulder.
- The bursa is identified and carefully excised.
- Surrounding tissues are inspected for any additional issues.
- The incision is closed with sutures or staples, and a sterile dressing is applied.
Preparation for the Procedure
Proper preparation is essential for a successful outcome.
- Discuss any medications with your doctor, especially blood thinners.
- Avoid eating or drinking for several hours before the procedure.
- Arrange for transportation home post-surgery.
- Wear loose-fitting clothing for easy access to the shoulder.
- Follow any specific instructions provided by your healthcare team.
Recovery and Aftercare
Post-operative care is vital for optimal recovery.
- Rest the shoulder and avoid heavy lifting for several weeks.
- Follow-up appointments to monitor healing.
- Pain management with prescribed medications.
- Physical therapy may be recommended to restore strength and mobility.
- Keep the surgical site clean and dry, changing dressings as instructed.
Possible Complications
As with any surgical procedure, there are potential risks.
- Infection at the surgical site.
- Excessive bleeding or hematoma formation.
- Nerve damage leading to weakness or numbness.
- Persistent pain or stiffness in the shoulder.
- Recurrence of bursitis.
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Post-Procedure Follow-Up
Regular follow-up is important to ensure proper healing.
- Initial follow-up within 1-2 weeks post-surgery.
- Additional visits may be scheduled based on recovery progress.
- Assessment of pain levels and range of motion.
- Discussion of physical therapy options if needed.
Alternative Treatments
There are non-surgical options available for managing shoulder bursitis.
- Physical therapy to strengthen shoulder muscles.
- Corticosteroid injections to reduce inflammation.
- Non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief.
- Activity modification to avoid aggravating movements.
- Heat or ice therapy to manage symptoms.
Home Care Tips
Simple home care can aid in recovery.
- Apply ice packs to reduce swelling in the first few days.
- Keep the arm elevated to minimize swelling.
- Engage in gentle range-of-motion exercises as advised.
- Avoid strenuous activities until cleared by your doctor.
- Monitor for signs of infection, such as increased redness or discharge.
Patient Education & Prevention
Education is key to preventing recurrence.
- Maintain a healthy weight to reduce joint stress.
- Incorporate shoulder-strengthening exercises into your routine.
- Avoid repetitive overhead activities when possible.
- Use proper techniques during sports and physical activities.
- Seek early treatment for shoulder pain to prevent worsening.
Billing and Coding Information
CPT Code: 23000
Category: Surgery
Common Modifiers:
- 50 - Bilateral procedure
- RT - Right side
- LT - Left side
Average Cost and Insurance Coverage
Costs can vary based on several factors.
- Average cost ranges from $3,000 to $7,000.
- Insurance may cover the procedure if deemed medically necessary.
- Out-of-pocket costs depend on the insurance plan and deductible.
- Pre-authorization may be required by some insurance providers.
Related CPT Codes
Frequently Asked Questions (FAQs)
What is the purpose of the excision of the shoulder bursa?
The procedure aims to relieve pain and improve shoulder function by removing the inflamed bursa.
How long does the recovery take?
Recovery typically takes several weeks, with gradual return to normal activities.
Will I need physical therapy after the procedure?
Yes, physical therapy is often recommended to restore strength and mobility.
Are there any risks associated with this surgery?
As with any surgery, there are risks such as infection, bleeding, and nerve damage.
How can I prevent shoulder bursitis from recurring?
Maintaining a healthy weight, strengthening shoulder muscles, and avoiding repetitive overhead activities can help.
