How To Use CPT Code 23931

CPT code 23931 describes the procedure of incision and drainage of a bursa in the upper arm or elbow area. 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 23931?

CPT 23931 is used to describe the incision and drainage of a bursa in the upper arm or elbow area. This procedure is performed to relieve pain, pressure, and infection from a localized site. The provider makes an incision, drains the fluid from the bursa, irrigates the wound, and closes the incision in layers if necessary.

2. Official Description

The official description of CPT code 23931 is: ‘Incision and drainage, upper arm or elbow area bursa.’

3. Procedure

During the procedure, the patient is appropriately prepped and anesthetized. The provider makes an incision at the site on the upper arm or elbow area where the bursa is located. They perform a microdissection to visualize the bursa and then incise it to drain the fluid. The provider may also irrigate the wound to wash out any remaining fluid or debris. If necessary, they close the incision in layers and may leave a drain in place to remove any further discharge that may occur.

4. Qualifying circumstances

CPT 23931 is performed on patients who have a localized bursa in the upper arm or elbow area that requires incision and drainage. The procedure is typically done to relieve pain, pressure, and infection. The patient must meet the criteria for the procedure, and the provider must determine that it is medically necessary.

5. When to use CPT code 23931

CPT code 23931 should be used when a provider performs an incision and drainage procedure on a bursa in the upper arm or elbow area. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 23931, the provider must document the following information:

• Patient’s diagnosis and the need for incision and drainage of the bursa
• Details of the procedure, including the site of the incision and the size of the bursa
• Any complications or additional procedures performed
• Post-procedure instructions and follow-up plans
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 23931, ensure that the procedure meets the specific criteria outlined in the code description. It is important to follow the appropriate coding guidelines and modifiers, if applicable. Report CPT 23931 separately for each bursa incised and drained. It is also important to review any payer-specific guidelines or requirements for accurate billing.

8. Historical information

CPT 23931 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 23931

There are several similar codes to CPT 23931 that describe procedures on the upper arm and elbow area. These include:

• CPT 23930: Incision and drainage, shoulder area bursa
• CPT 23932: Excision of subdeltoid or subacromial bursa
• CPT 23933: Excision of prepatellar bursa
• CPT 23934: Excision of olecranon bursa
• CPT 23935: Excision of bursa, elbow

9. Examples

1. A patient presents with a swollen and painful bursa in their upper arm. The provider performs an incision and drainage procedure on the bursa to relieve the symptoms.
2. An individual develops an infected bursa in their elbow area. The provider performs an incision and drainage procedure to remove the infected fluid and alleviate the infection.
3. A patient experiences chronic pain and pressure in their upper arm due to a bursa. The provider performs an incision and drainage procedure to relieve the pain and pressure.
4. An individual sustains an injury to their elbow, resulting in a swollen bursa. The provider performs an incision and drainage procedure to reduce the swelling and promote healing.
5. A patient with an infected bursa in their upper arm seeks medical attention. The provider performs an incision and drainage procedure to remove the infected fluid and prevent further complications.
6. An individual develops a large bursa in their elbow area, causing discomfort and limited range of motion. The provider performs an incision and drainage procedure to alleviate the symptoms and improve mobility.
7. A patient presents with a painful and inflamed bursa in their upper arm. The provider performs an incision and drainage procedure to relieve the pain and reduce inflammation.
8. An individual experiences recurrent infections in their elbow bursa. The provider performs an incision and drainage procedure to remove the infected fluid and prevent future infections.
9. A patient develops a bursa in their upper arm due to repetitive motion. The provider performs an incision and drainage procedure to alleviate the symptoms and prevent further complications.
10. An individual sustains a traumatic injury to their elbow, resulting in a swollen and painful bursa. The provider performs an incision and drainage procedure to reduce the swelling and relieve the pain.