How To Use CPT Code 25023

CPT code 25023 describes a surgical procedure known as decompression fasciotomy, which involves relieving pressure in the forearm and/or wrist by incising the fascial tissue and removing nonviable muscle and/or nerve tissue. 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 25023?

CPT code 25023 is used to describe a surgical procedure called decompression fasciotomy. This procedure involves making an incision in the forearm and/or wrist to relieve pressure in the fascial tissue. During the procedure, the healthcare provider may also remove nonviable muscle and/or nerve tissue. Decompression fasciotomy is typically performed to treat compartment syndrome, a condition characterized by a critical build-up of pressure within a membrane-covered compartment that can cause damage to delicate structures if not promptly addressed.

2. Official Description

The official description of CPT code 25023 is: ‘Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment with debridement of nonviable muscle and/or nerve.’

3. Procedure

During a decompression fasciotomy (CPT 25023), the healthcare provider performs the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision in the forearm, extending to the mid palm.
3. The fascia is incised to access the compartment.
4. The provider checks the pressure in the compartment to ensure adequate decompression.
5. The tissues are inspected, and any nonviable muscle or nerve tissue is debrided.
6. The area is irrigated, bleeding is checked, and any instruments are removed.
7. The incision is closed.

4. Qualifying circumstances

CPT code 25023 is typically used for patients with compartment syndrome in the forearm and/or wrist. Compartment syndrome occurs when there is a critical build-up of pressure within a membrane-covered compartment that contains vessels, nerves, and other structures. The procedure involves decompressing the flexor or extensor compartment and may include debridement of nonviable muscle and/or nerve tissue.

5. When to use CPT code 25023

CPT code 25023 should be used when a healthcare provider performs a decompression fasciotomy in the forearm and/or wrist, specifically targeting the flexor or extensor compartment. This code is appropriate when the procedure involves relieving pressure and removing nonviable muscle and/or nerve tissue. It is important to note that CPT code 25023 should not be used for brachial artery exploration; instead, code 24495 should be used for that specific procedure.

6. Documentation requirements

To support a claim for CPT code 25023, the healthcare provider must document the following information:

• Patient’s diagnosis of compartment syndrome
• Specific compartments targeted (flexor or extensor)
• Details of the procedure, including incision location and size
• Description of any nonviable muscle or nerve tissue debrided
• Confirmation of pressure relief in the compartment
• Documentation of irrigation, bleeding control, and closure of the incision

7. Billing guidelines

When billing for CPT code 25023, ensure that the procedure performed matches the description of decompression fasciotomy in the forearm and/or wrist, targeting the flexor or extensor compartment. It is important to note that CPT code 25023 should not be reported if brachial artery exploration is also performed; in such cases, code 24495 should be used instead. Additionally, consider the location of the testing when coding for pulmonary function tests (PFTs), as they have both a professional and technical component.

8. Historical information

CPT code 25023 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2002, with an updated description that included debridement of nonviable muscle and/or nerve tissue.

9. Similar codes to CPT 25023

There are several similar codes to CPT code 25023 that describe related procedures. These include:

• CPT 25020: Incision and drainage of the forearm and/or wrist
• CPT 25025: Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment without debridement of nonviable muscle and/or nerve
• CPT 25040: Incision and drainage of the deep fascia of the forearm and/or wrist
• CPT 24495: Exploration, brachial artery
• CPT 11010: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

9. Examples

Here are some examples of cases where CPT code 25023 may be used:

1. A patient presents with compartment syndrome in the flexor compartment of the forearm. The healthcare provider performs a decompression fasciotomy, relieving pressure and removing nonviable muscle tissue.
2. A patient is diagnosed with compartment syndrome in the extensor compartment of the wrist. The healthcare provider performs a decompression fasciotomy, relieving pressure and removing nonviable nerve tissue.
3. A patient experiences compartment syndrome in both the flexor and extensor compartments of the forearm. The healthcare provider performs a decompression fasciotomy, targeting both compartments and removing nonviable muscle and nerve tissue.
4. A patient presents with compartment syndrome in the flexor compartment of the wrist. The healthcare provider performs a decompression fasciotomy, relieving pressure and removing nonviable muscle and nerve tissue.
5. A patient is diagnosed with compartment syndrome in the extensor compartment of the forearm. The healthcare provider performs a decompression fasciotomy, relieving pressure and removing nonviable muscle tissue.