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Official Description

Incision and drainage, upper arm or elbow area; bursa

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 23931 involves the incision and drainage of an infected bursa located in the upper arm or elbow area. A bursa is a small, fluid-filled sac that serves to reduce friction between tissues of the body, such as between bone and tendons or muscles. When a bursa becomes infected, it can lead to significant discomfort and swelling, necessitating surgical intervention. The incision and drainage procedure aims to alleviate these symptoms by removing the infected fluid and allowing the bursa to heal properly. The surgical approach is determined by the specific location of the infected bursa, and the procedure may involve flushing the bursal sac with antibiotic or saline solutions to ensure thorough cleaning before closure. This intervention is critical in preventing further complications and promoting recovery in patients suffering from bursitis or similar conditions affecting the upper arm or elbow region.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 23931 is indicated for the following conditions:

  • Infected Bursa The primary indication for this procedure is the presence of an infected bursa, which can cause pain, swelling, and limited mobility in the affected area.
  • Symptoms of Bursitis Patients may present with symptoms consistent with bursitis, including localized tenderness, warmth, and swelling over the joint or prominent body part.
  • Abscess Formation The procedure may also be indicated if there is an accumulation of pus within the bursa, leading to an abscess that requires drainage to prevent further complications.

2. Procedure

The procedure for CPT® Code 23931 involves several key steps to ensure effective incision and drainage of the infected bursa:

  • Step 1: Anesthesia The procedure typically begins with the administration of local anesthesia to the area surrounding the infected bursa to ensure patient comfort during the incision and drainage process.
  • Step 2: Incision A surgical incision is made over the site of the infected bursa. The size and location of the incision are determined based on the bursa's position and the extent of the infection.
  • Step 3: Drainage Once the incision is made, the surgeon carefully dissects the soft tissues to access the bursal sac. The infected fluid is then drained from the bursa, which may involve the use of suction or manual expression to ensure complete evacuation of the pus.
  • Step 4: Flushing After the fluid has been drained, the bursal sac is flushed with an antibiotic solution and/or normal saline to cleanse the area and reduce the risk of further infection.
  • Step 5: Closure Depending on the extent of the infection and the surgeon's assessment, the bursal sac may be left open to allow for continued drainage, packed with gauze, or closed with sutures to promote healing.

3. Post-Procedure

Post-procedure care for patients undergoing CPT® Code 23931 includes monitoring the incision site for signs of infection, such as increased redness, swelling, or discharge. Patients are typically advised to keep the area clean and dry, and they may be prescribed antibiotics to prevent further infection. Pain management may also be necessary, and patients should be instructed on how to care for the incision site, including any dressing changes. Follow-up appointments may be scheduled to assess healing and determine if further intervention is required.

Short Descr I&D UPR A/E BURSA
Medium Descr INCISION&DRAINAGE UPPER ARM/ELBOW BURSA
Long Descr Incision and drainage, upper arm or elbow area; bursa
Status Code Active Code
Global Days 010 - Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies 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) P3D - Major procedure, orthopedic - other
MUE 2
CCS Clinical Classification 160 - Other therapeutic procedures on muscles and tendons

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)
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
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).
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
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.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
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.)
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CR Catastrophe/disaster related
GC This service has been performed in part by a resident under the direction of a teaching physician
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
RT Right side (used to identify procedures performed on the right side of the body)
SG Ambulatory surgical center (asc) facility service
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
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2023-01-01 Note Short description changed.
Pre-1990 Added Code added.
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