How To Use CPT Code 28002

CPT 28002 describes the procedure of incision and drainage below the fascia in the foot, involving a single bursal space. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 28002?

CPT 28002 is a code used to describe a specific surgical procedure performed on the foot. It involves making an incision below the fascia, a layer of fibrous tissue, to drain infected material from a single bursal space. This procedure is typically performed to alleviate pain and prevent further complications caused by the infection.

2. Official Description

The official description of CPT code 28002 is: ‘Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space.’

3. Procedure

1. The provider begins by preparing the patient and administering anesthesia to ensure their comfort during the procedure.
2. An incision is made through the skin and fascia to expose the infected area.
3. The provider removes the infected tissue and drains any fluid present in the bursal space.
4. If necessary, the provider may also remove the bursal sac and debride the tendon sheath.
5. Samples of the infected material may be collected and sent to a laboratory for analysis.
6. If the wound is large, the provider may leave it open after appropriate debridement and irrigation, treat it with antibiotics, and pack it with a suitable dressing. Otherwise, the wound is irrigated with antibiotic solution and closed with sutures.

4. Qualifying circumstances

CPT 28002 is used when the incision and drainage procedure is performed below the fascia in the foot, specifically targeting a single bursal space. It may involve the tendon sheath, but this is not a requirement for reporting this code. The procedure is typically performed to treat infections and relieve symptoms caused by the accumulation of fluid in the bursal space.

5. When to use CPT code 28002

CPT code 28002 should be used when the provider performs an incision and drainage procedure below the fascia in the foot, specifically targeting a single bursal space. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure involves multiple bursal spaces, a different code should be used.

6. Documentation requirements

To support a claim for CPT 28002, the provider must document the following information:

• Patient’s diagnosis and the need for the incision and drainage procedure
• Details of the procedure, including the specific bursal space targeted
• Date of the procedure
• Any additional procedures performed, such as debridement or removal of the bursal sac
• Results of any laboratory analysis, if applicable
• Details of wound closure, if applicable
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 28002, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The provider should also follow any additional guidelines provided by the payer. It is important to note that CPT 28002 should not be reported if other incision and drainage codes (such as 10040 to 10160) are already reported for the same patient within the same time period.

8. Historical information

CPT 28002 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 patient presents with an infected bursal space in their foot. The provider performs an incision and drainage procedure below the fascia, targeting the single bursal space. CPT code 28002 should be reported for this procedure.
2. A patient has a painful bursal space in their foot, which is suspected to be infected. The provider performs an incision and drainage procedure, targeting the single bursal space below the fascia. CPT code 28002 is appropriate for this procedure.
3. A patient with a history of foot problems develops an infected bursal space. The provider performs an incision and drainage procedure below the fascia, targeting the single bursal space. CPT code 28002 should be used for this procedure.
4. A patient presents with a swollen and painful bursal space in their foot. The provider determines that an incision and drainage procedure is necessary. CPT code 28002 is reported for the procedure performed below the fascia, targeting the single bursal space.
5. A patient with a known bursal space infection in their foot undergoes an incision and drainage procedure. The provider makes an incision below the fascia, targeting the single bursal space. CPT code 28002 is appropriate for this procedure.