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Official Description

Incision and drainage, pelvis or hip joint area; infected bursa

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 26991 involves the incision and drainage of an infected bursa located in the pelvis or hip joint area. An infected bursa is a fluid-filled sac that can become inflamed and filled with pus due to infection, leading to pain and discomfort. The procedure begins with the surgeon making an incision in the skin directly over the infected bursa. This incision allows access to the bursa, which is then opened using a scalpel to facilitate drainage. The primary goal of this procedure is to relieve pressure, remove infected material, and promote healing. Following the drainage, the site is typically flushed with saline or an antibiotic solution to help clear any remaining infection and reduce the risk of further complications. Depending on the extent of the infection and the surgeon's assessment, drains may be placed to allow for continued drainage of any fluid that may accumulate post-operatively. The incision may be closed in layers to promote proper healing or packed with gauze and left open to allow for further drainage and monitoring of the site.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 26991 is indicated for the treatment of an infected bursa in the pelvis or hip joint area. The following conditions may warrant this procedure:

  • Infected Bursa The primary indication for this procedure is the presence of an infected bursa, which can cause significant pain and swelling in the affected area.
  • Abscess Formation If the bursa has developed an abscess due to infection, leading to localized pus accumulation, incision and drainage are necessary to alleviate symptoms.
  • Persistent Symptoms Patients experiencing persistent pain, swelling, or limited mobility in the hip or pelvic region despite conservative treatment may require this intervention.

2. Procedure

The procedure for CPT® Code 26991 involves several critical steps to ensure effective drainage of the infected bursa. The following procedural steps are performed:

  • Step 1: Incision The surgeon begins by making a precise incision in the skin over the site of the infected bursa. This incision is carefully placed to provide optimal access to the underlying tissue.
  • Step 2: Opening the Bursa Once the incision is made, the surgeon uses a scalpel to open the infected bursa. This step is crucial as it allows for the drainage of pus and infected fluid that has accumulated within the bursa.
  • Step 3: Drainage After the bursa is opened, the surgeon drains the infected material. This may involve breaking up any loculations within the bursa to ensure complete drainage of the infected contents.
  • Step 4: Flushing the Site Following drainage, the surgical site is flushed with saline or an antibiotic solution. This step helps to cleanse the area and reduce the risk of further infection.
  • Step 5: Placement of Drains If necessary, drains may be placed in the cavity to facilitate ongoing drainage of any residual fluid and to prevent re-accumulation.
  • Step 6: Closure Finally, the incision may be closed in layers to promote healing, or it may be packed with gauze and left open, depending on the surgeon's assessment of the infection and the need for continued drainage.

3. Post-Procedure

After the procedure, patients may require specific post-operative care to ensure proper healing and monitor for any complications. It is essential to keep the incision site clean and dry, and patients may be advised to change dressings as instructed. Pain management may be necessary, and patients should be monitored for signs of infection, such as increased redness, swelling, or discharge from the incision site. Follow-up appointments may be scheduled to assess healing and determine if further intervention is needed. If drains were placed, instructions on how to care for them and when to return for removal will be provided. Overall, the recovery process will vary based on the individual patient's condition and the extent of the infection treated.

Short Descr DRAINAGE OF PELVIS BURSA
Medium Descr I&D PELVIS/HIP JOINT AREA INFECTED BURSA
Long Descr Incision and drainage, pelvis or hip joint area; infected bursa
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) 0 - 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) P5B - Ambulatory procedures - musculoskeletal
MUE 1
CCS Clinical Classification 162 - Other OR therapeutic procedures on joints

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)
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).
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)
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
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