Summary & Overview
CPT 23931: Incision and Drainage of Upper Arm/Elbow Bursa
CPT code 23931 represents the incision and drainage of a bursa in the upper arm or elbow region, a focused minor surgical procedure used to relieve pain, pressure, or local infection. Nationally, this code matters because it captures management of common soft-tissue infections and inflammatory bursitis that present across outpatient, emergency, and ambulatory surgical settings. Accurate coding affects clinical documentation, care pathways, and payment for a frequently performed, low-complexity procedure.
Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context for bursal drainage, typical sites of service where CPT code 23931 is used, and the common reimbursement and billing considerations tied to this service. The publication outlines national benchmarks where available, highlights relevant policy and coding updates that influence claim adjudication, and summarizes documentation elements that support medical necessity.
Intended for clinicians, coding professionals, and payer policy analysts, the content helps stakeholders understand where CPT code 23931 fits within procedural coding, expected care settings, and high-level billing implications. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 23931 describes the surgical incision and drainage of a bursa in the upper arm or elbow area. This procedure involves incising an inflamed or infected bursal sac and draining accumulated fluid to relieve pain, pressure, and infection at a localized site.
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Service type: Minor surgical procedure (incision and drainage of bursa)
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Typical site of service: Ambulatory surgical center, hospital outpatient department, emergency department, or physician office for upper arm or elbow bursal drainage
Clinical & Coding Specifications
Clinical Context
A 45-year-old right-handed male presents to the orthopedic clinic with a three-day history of progressive swelling, erythema, and localized tenderness over the olecranon bursa of the right elbow following minor repeated pressure from leaning on the arm at work. On exam there is fluctuance consistent with fluid collection and increased local warmth; range of motion of the elbow is otherwise preserved. The clinician evaluates for systemic infection (fever, leukocytosis) and obtains point-of-care ultrasound to confirm a fluid-filled bursal sac. After informed consent, the provider performs an incision and drainage of the olecranon bursa under local anesthesia in the procedure room to relieve pain and evacuate purulent fluid for culture and sensitivity. The workflow includes pre-procedure time-out, local field preparation, sterile draping, anesthesia (local infiltration), incision and drainage with gentle probing and aspiration of contents, wound culture collection, hemostasis, dressing application, and post-procedure discharge instructions including wound care and follow-up.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service on the same day | Use when a distinct E/M visit was provided on the same date separate from the incision and drainage procedure. |
| 22 | Increased procedural services | Use when the procedure required substantially more work or complexity than typical (documented rationale and supporting operative note).