Summary & Overview
CPT 28002: Incision and Drainage of Infected Bursa Involving Tendon Covering
CPT code 28002 covers incision and drainage of a bursa when infected material may involve the tendon covering. The code identifies a focused minor surgical procedure used to evacuate purulent fluid, relieve pain, and reduce the risk of deeper soft-tissue infection. Nationally, accurate coding of these procedures affects facility and professional billing, influences clinical documentation standards, and supports appropriate utilization tracking for common soft-tissue infections.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context for the procedure, common sites of service, and what to expect in billing practice. The publication outlines reimbursement benchmarks where available, typical coding considerations, and recent policy updates that impact coverage and medical necessity determinations. Clinical context covers indications for drainage of infected bursae and procedural scope relevant to coding decisions. The content is intended for coding professionals, clinicians who perform minor surgical drainage procedures, and policy analysts seeking national-level understanding of billing and coverage considerations for this CPT-coded service.
Data not available in the input: specific payer fee schedules, associated taxonomies, ICD-10 diagnosis mappings, and related codes.
Billing Code Overview
CPT code 28002 describes an incision of a bursa to drain infected material that may involve the tendon covering. The procedure is a surgical incision and drainage of a bursal infection, performed to evacuate purulent or inflammatory fluid from a bursa and to relieve pain and prevent spread of infection.
-
Service type: Surgical incision and drainage (minor operative procedure)
-
Typical site of service: Procedure is commonly performed in ambulatory surgical centers, hospital outpatient departments, emergency departments, or procedure rooms depending on clinical severity and setting.
Clinical & Coding Specifications
Clinical Context
A 48-year-old right-handed patient presents to the outpatient orthopedic clinic with a 5-day history of increasing pain, swelling, warmth, and limited range of motion over the lateral aspect of the elbow. The patient reports fever and difficulty bending the elbow. Physical exam demonstrates fluctuance and severe tenderness localized to the olecranon bursa with overlying erythema. Point-of-care ultrasound confirms an anechoic to complex fluid collection within the bursal sac consistent with infected bursitis. The treating orthopedic surgeon documents failure of conservative therapy (oral antibiotics and immobilization) and recommends surgical drainage.
The clinical workflow includes pre-procedure evaluation (consent, antibiotic administration as indicated, sterile preparation), local or regional anesthesia in an ambulatory surgery center or procedure room, incision and drainage of the bursa with evacuation of purulent material and copious irrigation, specimen collection for Gram stain and culture, possible exploration of the tendon sheath if involved, hemostasis, wound packing or primary/secondary closure per surgeon judgment, and post-procedure instructions with follow-up for culture results and wound care. Typical sites of service are an ambulatory surgery center, hospital outpatient department, or emergency department procedure room depending on acuity.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure |