How To Use CPT Code 20525

CPT code 20525 describes the removal of a foreign body deeply lodged in the muscle or tendon sheath through a surgical incision. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 20525?

CPT 20525 is used to describe the removal of a foreign body that is deeply lodged in the muscle or tendon sheath. This procedure involves making a surgical incision at the site of the foreign body to relieve swelling, pain, and difficulty in movement of the affected body part.

2. Official Description

The official description of CPT code 20525 is: ‘Removal of foreign body in muscle or tendon sheath deep or complicated.’

3. Procedure

1. The patient is appropriately prepped and the area is anesthetized.
2. The provider makes a surgical incision over the targeted area and separates the tissues.
3. If necessary, the provider may need to perform more difficult dissection or remove necrotic tissue.
4. The foreign body is located and removed.
5. The surgical opening is closed with sutures after thoroughly cleaning the site.
6. X-ray images may be used to locate the foreign body and ensure complete removal.

4. Qualifying circumstances

CPT 20525 is performed when a foreign body, such as a thorn, wood particle, bullet, or gravel, is deeply lodged in the muscle or tendon sheath. The procedure is done to relieve symptoms such as swelling, pain, and difficulty in movement. It is important to note that this code should not be used for foreign body removal in specific body parts if there are separate codes available for those areas.

5. When to use CPT code 20525

CPT code 20525 should be used when a foreign body is deeply lodged in the muscle or tendon sheath and requires surgical removal. It is important to ensure that the foreign body is causing symptoms such as swelling, pain, or difficulty in movement before using this code. If there are separate codes available for foreign body removal in specific body parts, those codes should be used instead.

6. Documentation requirements

To support a claim for CPT 20525, the following documentation is required:

• Patient’s symptoms and the need for foreign body removal
• Description of the foreign body and its location
• Date of the procedure
• Details of the surgical incision and removal process
• Any additional procedures performed, such as dissection or removal of necrotic tissue
• Post-procedure X-ray images, if applicable
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 20525, ensure that the procedure involves the removal of a foreign body deeply lodged in the muscle or tendon sheath. It is important to report radiologic imaging separately if performed. If there are separate codes available for foreign body removal in specific body parts, those codes should be used instead of CPT 20525. It is also important to report the appropriate modifiers, if applicable, and follow any specific guidelines provided by the payer.

8. Historical information

CPT 20525 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient presents with a deeply lodged wood particle in their forearm muscle. The provider performs a surgical incision and removes the foreign body.
2. A patient has a bullet lodged deeply in their thigh muscle. The provider makes an incision, locates the bullet, and removes it.
3. A patient has a thorn deeply lodged in their foot tendon sheath. The provider performs a surgical procedure to remove the thorn and relieve the patient’s symptoms.
4. A patient has gravel deeply lodged in their hand muscle. The provider performs a surgical incision, removes the gravel, and closes the incision with sutures.
5. A patient has a bone fragment deeply lodged in their shoulder muscle. The provider performs a surgical procedure to remove the fragment and improve the patient’s range of motion.
6. A patient has a metal shard deeply lodged in their calf muscle. The provider makes an incision, locates the shard, and removes it to alleviate the patient’s pain and swelling.
7. A patient has a foreign body deeply lodged in their wrist tendon sheath. The provider performs a surgical procedure to remove the foreign body and restore normal movement.
8. A patient has a bullet deeply lodged in their back muscle. The provider makes an incision, removes the bullet, and closes the incision to relieve the patient’s pain and improve mobility.
9. A patient has a wood particle deeply lodged in their finger tendon sheath. The provider performs a surgical procedure to remove the particle and alleviate the patient’s symptoms.
10. A patient has a thorn deeply lodged in their foot muscle. The provider makes an incision, locates the thorn, and removes it to relieve the patient’s pain and improve mobility.