Overview of CPT Code 23031: Removal of shoulder bursa
CPT Code 23031 refers to the surgical procedure for the removal of the shoulder bursa, a fluid-filled sac that reduces friction between tissues in the shoulder joint. This procedure is typically performed when the bursa becomes inflamed or causes pain, impacting the patient's mobility and quality of life.
When CPT Code 23031 is Used?
This procedure is indicated in several clinical scenarios.
- Chronic shoulder pain due to bursitis that has not responded to conservative treatments.
- Significant swelling or inflammation of the bursa affecting shoulder function.
- Presence of calcific deposits in the bursa causing pain and limited range of motion.
- Recurrent shoulder impingement syndrome linked to bursal inflammation.
Symptoms Indicating This Procedure
Patients may report various symptoms that lead to the consideration of this procedure.
- Persistent shoulder pain, especially during movement.
- Swelling or tenderness over the shoulder joint.
- Limited range of motion in the shoulder.
- Pain that worsens at night or with overhead activities.
Causes and Risk Factors
Understanding the causes and risk factors can help in prevention and management.
- Repetitive overhead activities, common in athletes and manual laborers.
- Age-related degeneration of shoulder structures.
- Previous shoulder injuries or surgeries.
- Conditions such as rheumatoid arthritis or gout.
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 the condition of the bursa and surrounding tissues.
- Ultrasound to visualize inflammation or fluid accumulation.
- Blood tests to check for underlying inflammatory conditions.
Procedure Description
The removal of the shoulder bursa is performed under sterile conditions.
- The patient is positioned comfortably, usually in a sitting or lying position.
- Local anesthesia is administered to numb the area around the shoulder.
- An incision is made over the bursa to access the inflamed tissue.
- The bursa is carefully excised, and any surrounding inflamed tissue may also be removed.
- The incision is closed with sutures, and a sterile dressing is applied.
Preparation for the Procedure
Proper preparation is essential for a successful outcome.
- Avoid blood thinners and anti-inflammatory medications as advised by the physician.
- Arrange for transportation to and from the procedure.
- Follow fasting instructions if general anesthesia is planned.
- Discuss any allergies or medical conditions with the healthcare provider.
Recovery and Aftercare
Post-operative care is crucial for optimal recovery.
- Rest the shoulder and avoid strenuous activities for several weeks.
- Follow up with the healthcare provider for suture removal if necessary.
- Apply ice packs to reduce swelling and pain.
- Take prescribed pain medications as directed.
Possible Complications
While complications are rare, they can occur.
- Infection at the surgical site.
- Persistent pain or stiffness in the shoulder.
- Nerve damage leading to weakness or numbness.
- Recurrence of bursitis.
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Post-Procedure Follow-Up
Regular follow-up is important to monitor recovery.
- Initial follow-up appointment within 1-2 weeks post-surgery.
- Additional visits may be scheduled to assess healing and function.
- Physical therapy may be recommended to restore strength and mobility.
Alternative Treatments
There are non-surgical options available for managing shoulder bursitis.
- Physical therapy to strengthen shoulder muscles and improve range of motion.
- Corticosteroid injections to reduce inflammation.
- Non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief.
- Activity modification to avoid aggravating the condition.
Home Care Tips
Patients can take steps at home to aid recovery.
- Keep the surgical area clean and dry.
- Use ice packs to manage swelling and discomfort.
- Follow the prescribed exercise regimen to regain strength.
- Avoid heavy lifting or overhead activities until cleared by the doctor.
Patient Education & Prevention
Education is key to preventing recurrence.
- Engage in shoulder-strengthening exercises to prevent future issues.
- Avoid repetitive overhead activities when possible.
- Maintain a healthy weight to reduce stress on joints.
- Seek early treatment for shoulder pain to prevent worsening conditions.
Billing and Coding Information
CPT Code: 23031
Category: Surgical Procedures
Common Modifiers:
- -50
- -RT
- -LT
Average Cost and Insurance Coverage
Costs can vary based on location and insurance.
- Average cost ranges from $3,000 to $7,000 depending on facility and anesthesia.
- Most insurance plans cover the procedure if deemed medically necessary.
- Out-of-pocket costs may apply depending on the insurance plan.
Related CPT Codes
Frequently Asked Questions (FAQs)
What is a shoulder bursa?
A shoulder bursa is a small fluid-filled sac that helps reduce friction between the shoulder joint and surrounding tissues.
How long does recovery take?
Recovery typically takes several weeks, but full healing may take a few months depending on individual factors.
Will I need physical therapy after surgery?
Yes, physical therapy is often recommended to help restore strength and mobility in the shoulder.
Are there risks associated with this procedure?
As with any surgery, there are risks such as infection, nerve damage, and recurrence of symptoms.
