How To Use CPT Code 28003

CPT 28003 describes the procedure of incision and drainage below the fascia of the foot, involving multiple infected bursal spaces. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 28003?

CPT 28003 is used to describe the incision and drainage procedure performed below the fascia of the foot, specifically targeting multiple infected bursal spaces. This code is used when the provider makes an incision in the skin and fascia to expose the infection, removes the infected tissue, and drains the fluid. The procedure may also involve the removal of the bursal sac and the tendon sheath if necessary.

2. Official Description

The official description of CPT code 28003 is: ‘Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas.’

3. Procedure

1. After appropriate patient preparation and anesthesia, the provider makes an incision in the skin and fascia of the foot.
2. The incision allows access to the infected bursal spaces beneath the fascia.
3. The provider removes the infected tissue and drains the fluid from the bursal spaces.
4. If necessary, the provider may also remove the bursal sac and address any involvement of the tendon sheath.
5. After irrigating the area and treating it with antibiotics, the provider may leave the incision open if it is large, packing it with gauze.

4. Qualifying circumstances

CPT 28003 is used when the provider performs incision and drainage below the fascia of the foot, specifically targeting multiple infected bursal spaces. The procedure may or may not involve the tendon sheath. Bursa refers to a fluid-filled sac located between the muscle, tendon, and bones. This code should only be used for cases involving multiple areas of infection.

5. When to use CPT code 28003

CPT code 28003 should be used when the provider performs incision and drainage below the fascia of the foot, involving multiple infected bursal spaces. It is important to note that this code is specifically for cases with multiple areas of infection. If the procedure only involves a single bursal space, CPT code 28002 should be used instead.

6. Documentation requirements

To support a claim for CPT 28003, the provider must document the following information:

• Patient’s diagnosis and the need for incision and drainage
• Specific areas of infection targeted during the procedure
• Date of the procedure
• Details of the incision and drainage process
• Any additional procedures performed, such as removal of the bursal sac or involvement of the tendon sheath
• Post-procedure care, including irrigation, antibiotic treatment, and packing of the incision if applicable
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 28003, ensure that the procedure involves incision and drainage below the fascia of the foot, targeting multiple infected bursal spaces. It is important to follow the specific documentation requirements and guidelines for accurate billing. There are no specific notes regarding reporting CPT 28003 with other codes.

8. Historical information

CPT 28003 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 provider performs incision and drainage below the fascia of the foot, targeting multiple infected bursal spaces in a patient with cellulitis.
2. During the procedure, the provider removes infected tissue and drains fluid from multiple bursal spaces in a patient with septic bursitis.
3. A patient presents with an abscess in multiple bursal spaces of the foot, and the provider performs incision and drainage below the fascia to address the infection.
4. In a case of recurrent infection in multiple bursal spaces, the provider performs incision and drainage below the fascia of the foot to alleviate the condition.
5. A patient with an infected bursal space in multiple areas of the foot undergoes incision and drainage below the fascia to treat the infection.
6. During the procedure, the provider removes infected tissue and drains fluid from multiple bursal spaces in a patient with gouty arthritis.
7. A provider performs incision and drainage below the fascia of the foot, targeting multiple infected bursal spaces in a patient with rheumatoid arthritis.
8. In a case of chronic infection in multiple bursal spaces, the provider performs incision and drainage below the fascia of the foot to alleviate the symptoms.
9. A patient with an infected bursal space in multiple areas of the foot undergoes incision and drainage below the fascia to treat the infection.
10. During the procedure, the provider removes infected tissue and drains fluid from multiple bursal spaces in a patient with septic arthritis.