ICD-10-CM Billable Code

M71.01

Abscess of bursa, shoulder

Clinical Classification Guidelines

Medical Intelligence & Overview

An abscess of the shoulder bursa, classified under ICD-10 code M71.01, is a localized infection that leads to a pocket of pus forming within the bursa of the shoulder. The shoulder bursa is a small fluid-filled sac that helps reduce friction between tissues of the shoulder joint, facilitating smooth movement. An abscess in this area can cause significant discomfort and impair shoulder mobility, often requiring medical attention for proper management.

Causes & Symptoms

Clinical Causes: Bacterial infections introduced through a cut, scrape, or puncture wound near the shoulder Spread of infection from nearby tissues or skin Repeated shoulder trauma or overuse, leading to inflammation and increased susceptibility to infection Complication of underlying bursitis with bacterial invasion Infections resulting from invasive medical procedures involving the shoulder

Key Symptoms: Severe pain in the shoulder region, often worsening with movement Swelling and tenderness over the affected bursa Warmth and redness around the shoulder area Limited range of motion in the shoulder joint Fever and chills in some cases, indicating systemic infection Possible palpable fluctuant mass (a soft, fluid-filled swelling)

Diagnostic & Treatment

Diagnosis Path: Diagnosis typically involves a combination of clinical examination and imaging studies. The healthcare provider will assess symptoms and look for signs of inflammation or swelling. Imaging techniques such as ultrasound or MRI can visualize the abscess within the bursa. In some cases, a needle aspiration of the bursa may be performed to obtain a sample of the pus for microbiological analysis, which helps identify the causative bacteria and guide antibiotic therapy.

Treatment Protocols: {'antibiotics': 'Targeted antibiotic therapy based on microbiological findings to eliminate the bacterial infection', 'drainage': 'Procedural drainage of the abscess to remove pus and reduce pressure, often performed via needle aspiration or surgical incision', 'rest and immobilization': 'Limiting shoulder movement to promote healing and prevent further injury', 'pain management': 'Use of analgesics to control pain', 'follow-up care': 'Monitoring for signs of recurrence or complications and physical therapy to restore shoulder function after infection resolution'}

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is M71.01 a billable ICD-10 code?
Yes, M71.01 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report M71.01?
Clinical documentation must specify the nature of Abscess of bursa, shoulder and any associated comorbidities for accurate reporting.

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