How To Use CPT Code 21502

CPT 21502 describes the procedure of incision and drainage of a deep abscess or hematoma in the soft tissues of the neck or thorax, along with a partial rib ostectomy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21502?

CPT 21502 is used to describe the surgical procedure of incision and drainage of a deep abscess or hematoma in the soft tissues of the neck or thorax, along with the removal of a portion of a rib bone. This procedure is performed to relieve pain and pressure caused by a collection of pus or blood in the affected area.

2. Official Description

The official description of CPT code 21502 is: ‘Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax with partial rib ostectomy.’

3. Procedure

During the procedure, the healthcare provider prepares the patient and administers anesthesia. An incision is made over the site of the abscess or hematoma, allowing the provider to visualize the affected area. The abscess or hematoma is then incised, and the fluid is drained from the cavity. The provider irrigates the area to ensure thorough cleansing. Using surgical tools, the damaged portion of the rib bone is removed. The area is irrigated again, checked for bleeding, and any instruments are removed. Finally, the incision is closed.

4. Qualifying circumstances

CPT 21502 is performed on patients who have a deep abscess or hematoma in the soft tissues of the neck or thorax. The procedure involves a partial rib ostectomy, which means that a portion of a rib bone is removed. It is important to note that CPT 21502 should only be reported if both the incision and drainage of the abscess or hematoma and the partial rib ostectomy are performed during the same procedure.

5. When to use CPT code 21502

CPT code 21502 should be used when a healthcare provider performs an incision and drainage procedure for a deep abscess or hematoma in the soft tissues of the neck or thorax, along with a partial rib ostectomy. It is crucial to ensure that both components of the procedure are documented and performed during the same surgical session.

6. Documentation requirements

To support a claim for CPT 21502, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the presence of a deep abscess or hematoma
• Description of the incision and drainage procedure
• Documentation of the partial rib ostectomy
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider

7. Billing guidelines

When billing for CPT 21502, it is important to ensure that both the incision and drainage of the abscess or hematoma and the partial rib ostectomy are performed during the same procedure. If the rib ostectomy is not performed, CPT code 21501 should be used instead. It is also essential to follow any specific guidelines provided by the payer or insurance company regarding the use of CPT 21502.

8. Historical information

CPT 21502 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 21502

There are several similar codes to CPT 21502 that describe procedures involving incision and drainage of abscesses or hematomas in different anatomical locations. Some similar codes include:

• CPT 21501: Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax (without partial rib ostectomy)
• CPT 21503: Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax with costochondral separation (separate procedure)
• CPT 21504: Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax with costochondral separation (separate procedure) and partial rib ostectomy

9. Examples

1. A patient presents with a deep abscess in the soft tissues of the neck. The healthcare provider performs an incision and drainage procedure, along with a partial rib ostectomy to remove the infected tissue.
2. A patient has a hematoma in the thoracic region. The healthcare provider performs an incision and drainage procedure, along with a partial rib ostectomy to relieve the pressure and remove the accumulated blood.
3. A patient develops a deep abscess in the soft tissues of the neck following a previous surgical procedure. The healthcare provider performs an incision and drainage procedure, along with a partial rib ostectomy to address the infection and promote healing.
4. A patient sustains a traumatic injury to the chest, resulting in a hematoma. The healthcare provider performs an incision and drainage procedure, along with a partial rib ostectomy to evacuate the blood and alleviate pain.
5. A patient presents with a recurrent abscess in the soft tissues of the neck. The healthcare provider performs an incision and drainage procedure, along with a partial rib ostectomy to prevent further infection and promote healing.