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Official Description

Incision and drainage, leg or ankle; deep abscess or hematoma

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 27603 refers to the procedure of incision and drainage of a deep abscess or hematoma located in the leg or ankle. This procedure is typically performed when there is a collection of pus (abscess) or a localized collection of blood (hematoma) that requires surgical intervention. The process begins with making an incision in the skin directly over the site of the abscess or hematoma. The incision is extended through the soft tissue to access the underlying cavity. In cases of an abscess, the surgeon will carefully break up any loculations, which are compartments within the abscess, using a technique known as blunt finger dissection. This is essential to ensure that all infected material is adequately drained. For a hematoma, the procedure involves the removal of blood clots, often utilizing suction to clear the cavity. Following the drainage, the cavity is typically flushed with either saline or an antibiotic solution to help reduce the risk of infection and promote healing. This procedure is crucial for alleviating pain, preventing further complications, and facilitating recovery in patients with deep-seated infections or blood collections in the leg or ankle area.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 27603 is indicated for specific conditions that necessitate surgical intervention to alleviate symptoms and prevent complications. The following are the primary indications for performing an incision and drainage of a deep abscess or hematoma in the leg or ankle:

  • Deep Abscess: A localized collection of pus that has formed due to infection, often accompanied by swelling, redness, and pain in the affected area.
  • Hematoma: A collection of blood outside of blood vessels, typically resulting from trauma or injury, which can cause swelling and discomfort.

2. Procedure

The procedure for incision and drainage of a deep abscess or hematoma involves several critical steps to ensure effective treatment. Each step is designed to address the underlying issue while minimizing complications.

  • Step 1: The first step involves the identification of the abscess or hematoma site. The area is then prepared and sterilized to reduce the risk of infection.
  • Step 2: An incision is made in the skin directly over the identified site. This incision is carefully extended through the soft tissue to reach the abscess or hematoma cavity.
  • Step 3: If the procedure is for an abscess, the surgeon will perform blunt finger dissection to break up any loculations within the abscess, ensuring that all infected material is accessible for drainage.
  • Step 4: In cases of hematoma, the surgeon will remove any blood clots present in the cavity, often using suction to facilitate this process.
  • Step 5: After the cavity has been adequately drained, it is flushed with saline or an antibiotic solution to cleanse the area and help prevent infection.
  • Step 6: Depending on the extent of the procedure and the surgeon's assessment, drains may be placed to allow for continued drainage of any residual fluid.
  • Step 7: Finally, the incision may be closed in layers or packed with gauze and left open, depending on the clinical situation and the surgeon's preference.

3. Post-Procedure

After the incision and drainage procedure, patients are typically monitored for any signs of complications, such as infection or excessive bleeding. Post-procedure care may include instructions for wound care, pain management, and signs to watch for that may indicate complications. Patients may be advised to keep the area clean and dry, and follow-up appointments may be scheduled to assess healing and remove any drains if placed. Recovery time can vary based on the extent of the procedure and the patient's overall health.

Short Descr DRAIN LOWER LEG LESION
Medium Descr INCISION & DRAINAGE LEG/ANKLE ABSCESS/HEMATOMA
Long Descr Incision and drainage, leg or ankle; deep abscess or hematoma
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) 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) P5B - Ambulatory procedures - musculoskeletal
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)
20704 Add-on Code MPFS Status: Active Code APC N Manual preparation and insertion of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure)
20705 Add-on Code MPFS Status: Active Code APC N Removal of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure)
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.
LT Left side (used to identify procedures performed on the left side of the body)
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.
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.)
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.)
RT Right side (used to identify procedures performed on the right side of the body)
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
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.
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).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
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.
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.
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).
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CN 100 percent impaired, limited or restricted
CR Catastrophe/disaster related
ET Emergency services
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
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
SG Ambulatory surgical center (asc) facility service
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
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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2013-01-01 Changed Medium Descriptor changed.
Pre-1990 Added Code added.
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