How To Use CPT Code 27604

CPT 27604 describes the procedure of incision and drainage for an infected bursa in the leg or ankle. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 27604?

CPT 27604 is used to describe the incision and drainage procedure performed by a healthcare provider to treat an infected bursa in the leg or ankle. This code is used when the provider makes an incision, drains the infected bursa, and takes necessary steps to relieve pain and treat the infection.

2. Official Description

The official description of CPT code 27604 is: ‘Incision and drainage, leg or ankle; infected bursa.’

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. An incision is made in the leg or ankle over the infected bursa.
3. The provider dissects through the deep subcutaneous tissues, potentially extending the incision into the fascia or muscle to expose the infected bursa.
4. If necessary, the incision may be extended further if the infected bursa is larger than expected.
5. The provider identifies the infected bursa and makes an incision to drain its contents.
6. The area is irrigated with saline to cleanse it.
7. The incision is repaired in layers using sutures, staples, or sterile adhesive strips.
8. Drains may be placed or the incision may be left open to facilitate further drainage of the infection.

4. Qualifying circumstances

CPT 27604 is used when a patient has an infected bursa in the leg or ankle that requires incision and drainage. The procedure is performed by a healthcare provider to treat the infection and relieve pain. It is important to note that this code specifically applies to infected bursas and not other types of abscesses or hematomas.

5. When to use CPT code 27604

CPT code 27604 should be used when a healthcare provider performs the incision and drainage procedure on an infected bursa in the leg or ankle. It is important to accurately document the diagnosis and the need for the procedure in the patient’s medical record.

6. Documentation requirements

To support a claim for CPT 27604, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for incision and drainage
• Details of the procedure, including the location of the incision and the extent of dissection
• Any additional procedures performed, such as repair of the incision or placement of drains
• Any complications or unexpected findings during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 27604, ensure that the procedure is performed on an infected bursa in the leg or ankle. It is important to follow the specific documentation requirements and accurately code the procedure. There are no specific guidelines regarding reporting CPT 27604 with other codes.

8. Historical information

CPT 27604 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. Examples

1. A healthcare provider performs an incision and drainage procedure on an infected bursa in the leg of a patient with cellulitis.
2. An orthopedic surgeon performs an incision and drainage procedure on an infected bursa in the ankle of a patient with septic arthritis.
3. A podiatrist performs an incision and drainage procedure on an infected bursa in the foot of a patient with a diabetic foot ulcer.
4. An emergency room physician performs an incision and drainage procedure on an infected bursa in the leg of a patient with a sports-related injury.
5. A general surgeon performs an incision and drainage procedure on an infected bursa in the ankle of a patient with a history of recurrent infections.
6. An orthopedic surgeon performs an incision and drainage procedure on an infected bursa in the leg of a patient with osteomyelitis.
7. A plastic surgeon performs an incision and drainage procedure on an infected bursa in the ankle of a patient with a postoperative wound infection.
8. An interventional radiologist performs an incision and drainage procedure on an infected bursa in the leg of a patient with a deep vein thrombosis.
9. An orthopedic surgeon performs an incision and drainage procedure on an infected bursa in the ankle of a patient with rheumatoid arthritis.
10. A podiatrist performs an incision and drainage procedure on an infected bursa in the leg of a patient with gout.