Surgical incision and drainage of a foot infection extending into or below the deep fascial layer, involving soft tissue spaces of the foot.

Verified May 8, 2026 · 6 sources ↓

Medicare: $242.16
Work RVU: 2.72
Global, days: 0
Region: Foot & ankle

Drawn from CMSAAPCCgsmedicareMdclarityAAOS

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 6 cited references ↓

Operative note must explicitly state that incision extended through or below the deep fascia — 'standard I&D' language is insufficient
Identify the specific anatomical space or compartment entered (e.g., plantar space, deep interosseous space)
Describe the nature and extent of infection found (purulence, necrotic tissue, volume drained, tissue planes involved)
Document the surgical approach, instruments used, and wound management at closure or packing
ICD-10 diagnosis code must support infectious etiology — include underlying condition (e.g., diabetic foot infection, abscess) to justify medical necessity
If billing same-day E/M, document a separately identifiable evaluation beyond the decision to perform the procedure

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 25 Significant separate E/M 50 Bilateral procedure 51 Multiple procedures 59 Distinct service 76 Repeat, same physician 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 28002 covers incision and drainage of a foot infection at or below the deep fascial layer. This is a deeper, more invasive intervention than superficial I&D — the surgeon opens the foot to reach infected soft tissue compartments or spaces beneath the fascia. It carries a 000-day global period, meaning each encounter stands alone with no bundled postoperative care.

Distinguishing 28002 from shallower debridement or wound care codes hinges entirely on documentation depth. The operative note must explicitly state that the incision penetrated through or below fascia, name the compartment or space entered, and describe what was encountered (purulence, necrotic tissue, extent of involvement). Notes that just say 'I&D performed' without specifying depth consistently draw audits and downcodes.

This code appears predominantly in podiatry and orthopedic surgery settings, often in the context of diabetic foot infections, plantar space abscesses, and postoperative wound complications. If bone is exposed or biopsied during the same session, a separate code for open bone biopsy may be appropriate — but that requires independent documentation supporting both procedures as distinct services.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (2.72) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (7.25) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	2.72
Practice expense RVU	4.28
Malpractice RVU	0.25
Total RVU	7.25
Medicare national rate	$242.16
Global period	0 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$242.16
HOPD (APC 5112) Hospital outpatient department	$1,642.82
ASC (PI A2) Ambulatory surgical center (freestanding)	$872.87

Common denial reasons

The recurring reasons claims for CPT 28002 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Operative note lacks explicit documentation of depth reaching the fascial layer — payers downcode to a superficial I&D or wound care code
Diagnosis code mismatch: using a non-infectious or chronic wound ICD-10 that doesn't support acute surgical I&D
Bundling conflict when same-day services are not clearly documented as distinct — modifier 59 or XS omitted without supporting notes
Missing or vague procedure note that doesn't correlate the surgical findings to the preoperative physical examination
Same-day E/M billed without modifier 25 and without documentation of a significant, separately identifiable service

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01What separates 28002 from a simpler foot I&D code?

Depth. CPT 28002 requires that the incision reach or penetrate the deep fascia to access infected deep soft tissue spaces. Superficial I&D of skin and subcutaneous tissue only uses different codes. Your operative note must explicitly confirm fascial depth — not just that an I&D was performed.

02Can 28002 be billed with an E/M on the same day?

Yes, but append modifier 25 to the E/M and document a significant, separately identifiable service beyond the decision to perform the I&D. The visit note must stand on its own clinical merits — simply deciding to proceed with surgery doesn't qualify.

03If the same procedure is needed again a few days later, what modifier applies?

If the same physician repeats 28002 for the same infection, use modifier 76. If a different physician performs it, use modifier 77. Because the global period is 000, you won't be in a postoperative window — but the modifier still signals a deliberate repeat to prevent automated denial.

04Can 28002 and an open bone biopsy be billed together?

Potentially yes, if the bone biopsy is a truly distinct service supported by independent documentation. The operative note must clearly describe separate indications, separate tissue planes, and separate surgical decisions. Audit teams scrutinize these combinations closely — vague notes that conflate both procedures into one narrative are a denial risk.

05How does site of service affect reimbursement for 28002?

Significantly. HOPD reimbursement is substantially higher than ASC payment for this code. If your facility is billing at the HOPD rate, ensure the procedure is appropriately performed and documented in a hospital outpatient setting. See the site-of-service comparison table on this page for current 2026 figures.

06What ICD-10 codes pair with 28002?

Codes indicating active foot infection are required — deep abscess, diabetic foot infection with abscess, infected postoperative wound, or plantar space infection. Chronic wound or ulcer codes without an infectious component typically won't support medical necessity for a surgical I&D at the fascial level.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira Scribe

Mira's AI scribe captures the operative depth — specifically whether the incision entered through or below the deep fascia — along with the compartment name, description of infectious material encountered, and wound management performed. This prevents the most common 28002 denial: an underdocumented note that can't support the fascial depth required to distinguish this code from a superficial I&D.

See how Mira captures CPT 28002 documentation