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Official Description

Incision and drainage, bursa, foot

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

An incision and drainage procedure on a bursa of the foot, designated by CPT® Code 28001, is a surgical intervention aimed at alleviating discomfort caused by excessive fluid accumulation within the bursal sac, a condition known as bursitis. Bursae are small, fluid-filled sacs located in areas of the foot that experience high friction, such as over the heel and the metatarsal bones. These structures serve a critical role in reducing friction and acting as shock absorbers during movement. The procedure involves making an incision in the skin over the affected bursa, allowing for direct access to the inflamed sac. Once the incision is made, the bursal sac is carefully incised to facilitate the drainage of the accumulated fluid. After the fluid is removed, the incisions are meticulously closed in layers to promote proper healing and minimize the risk of infection. This procedure is typically indicated when conservative treatments have failed to relieve symptoms associated with bursitis, thereby providing a necessary intervention to restore function and alleviate pain in the affected area.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The incision and drainage of a bursa in the foot, as described by CPT® Code 28001, is indicated for the following conditions:

  • Bursitis - This condition involves inflammation of the bursa, often resulting in pain and swelling due to excessive fluid accumulation.
  • Excessive fluid buildup - The procedure is performed when there is a significant accumulation of fluid within the bursal sac that causes discomfort and impairs mobility.
  • Failure of conservative treatments - When non-surgical interventions, such as rest, ice, compression, and anti-inflammatory medications, do not provide adequate relief, this procedure may be warranted.

2. Procedure

The procedure for incision and drainage of a bursa in the foot involves several critical steps to ensure effective treatment of the condition.

  • Step 1: Preparation - The patient is positioned comfortably, and the area around the affected bursa is cleaned and sterilized to minimize the risk of infection. Local anesthesia may be administered to ensure the patient remains comfortable throughout the procedure.
  • Step 2: Incision - A precise incision is made in the skin overlying the inflamed bursa. The incision is typically made along the natural skin lines to promote better healing and minimize scarring.
  • Step 3: Drainage - Once the incision is made, the bursal sac is carefully accessed and incised to allow for the drainage of the accumulated fluid. The surgeon may use suction or a sterile instrument to facilitate the removal of the fluid, ensuring that the bursa is adequately drained.
  • Step 4: Closure - After the fluid has been successfully drained, the incision is closed in layers. The deeper layers of tissue are sutured first, followed by the closure of the skin layer to promote optimal healing and reduce the risk of complications.

3. Post-Procedure

Following the incision and drainage procedure, patients are typically monitored for any immediate complications. Post-procedure care may include instructions for wound care, such as keeping the incision site clean and dry, and possibly the application of a sterile dressing. Patients may be advised to avoid strenuous activities and to follow up with their healthcare provider to assess healing and address any concerns. Pain management may be recommended, and patients should be informed about signs of infection, such as increased redness, swelling, or discharge from the incision site, which would necessitate prompt medical attention.

Short Descr DRAINAGE OF BURSA OF FOOT
Medium Descr INCISION&DRAINAGE BURSA FOOT
Long Descr Incision and drainage, bursa, foot
Status Code Active Code
Global Days 000 - Endoscopic or 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) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
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 Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs.
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)
LT Left side (used to identify procedures performed on the left side of the body)
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.
RT Right side (used to identify procedures performed on the right side of the body)
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).
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.)
T6 Right foot, second digit
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.
AG Primary physician
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
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
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
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TA Left foot, great toe
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
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