© Copyright 2025 American Medical Association. All rights reserved.
The CPT® Code 21502 refers to a surgical procedure involving the incision and drainage of a deep abscess or hematoma located in the soft tissues of the neck or thorax, accompanied by a partial rib ostectomy. This procedure is typically indicated when there is a significant accumulation of pus or blood that requires intervention to prevent further complications. The physician initiates the process by making an incision in the skin directly over the site of the abscess or hematoma. This incision allows access to the underlying soft tissues, where the abscess or hematoma is located. The physician then carefully opens the abscess or hematoma to facilitate drainage. In cases of an abscess, any loculated areas are meticulously broken up using blunt finger dissection to ensure complete drainage. For hematomas, the physician employs suction to remove any clotted blood. Following the drainage, the cavity is thoroughly flushed with saline or an antibiotic solution to reduce the risk of infection. Depending on the situation, drains may be placed to allow for continued drainage of any residual fluid. The incision may be closed in layers or packed with gauze and left open to promote healing. In instances where the abscess involves the bone, a partial rib ostectomy is performed. This involves the excision of a portion of the rib to address any bony involvement or to manage a fistulous tract that may be present. The rib is carefully inspected for signs of destruction or granulation tissue, and any affected areas are resected to ensure complete resolution of the infection or hematoma.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 21502 is indicated for the following conditions:
The procedure involves several critical steps to ensure effective drainage and management of the abscess or hematoma:
Post-procedure care involves monitoring the surgical site for signs of infection, ensuring that drains are functioning properly, and managing any pain or discomfort. Patients may require follow-up visits to assess healing and to remove drains if placed. The physician will provide specific instructions regarding wound care, activity restrictions, and any necessary follow-up imaging or laboratory tests to ensure complete recovery.
| Short Descr | I&D DP ABS/HMTM NCK RIB OSTC | Medium Descr | I&D DP ABSC/HMTMA SFT TIS NCK/THRX PRTL RIB OSTC | Long Descr | Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomy | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 1 | CCS Clinical Classification | 142 - Partial excision bone |
This is a primary code that can be used with these additional add-on codes.
| 20700 | Add-on Code MPFS Status: Active Code APC N ASC N1 Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure) |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.