How To Use CPT Code 25110

CPT code 25110 describes the excision of a lesion from a tendon sheath in the forearm and/or wrist. 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 25110?

CPT 25110 is used to describe the excision of a lesion from a tendon sheath in the forearm and/or wrist. This procedure involves the removal of a diseased or damaged portion of the tendon sheath through an incision made in the wrist or forearm area. The provider may also repair any resultant defect and close the wound in layers.

2. Official Description

The official description of CPT code 25110 is: ‘Excision, lesion of tendon sheath, forearm and/or wrist.’

3. Procedure

The procedure for CPT 25110 involves the following steps:

1. The patient is placed under anesthesia.
2. The provider preps and drapes the site.
3. An incision is made in the wrist or forearm area.
4. Full-thickness skin flaps are reflected to reach the diseased/damaged tendon portion.
5. The provider isolates the appropriate section of the tendon sheath.
6. The lesion is excised from the tendon sheath.
7. If required, the resultant defect is repaired.
8. The wound is closed in layers.

4. Qualifying circumstances

CPT 25110 is typically performed on patients with a lesion in the tendon sheath of the forearm and/or wrist. The procedure is indicated when the lesion is causing symptoms or affecting the function of the affected area. The patient must meet the criteria for surgery and be an appropriate candidate for anesthesia.

5. When to use CPT code 25110

CPT code 25110 should be used when a provider performs an excision of a lesion from a tendon sheath in the forearm and/or wrist. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the excision is performed on a different anatomical site or involves a different type of lesion, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT 25110, the provider must document the following information:

• Patient’s diagnosis and the need for the excision
• Location and size of the lesion
• Details of the procedure, including the incision, excision, and repair (if applicable)
• Any complications or unexpected findings
• Post-operative care instructions
• Signature of the provider

7. Billing guidelines

When billing for CPT 25110, ensure that the procedure performed matches the description of the code. It is important to follow the specific guidelines provided by the payer and any applicable modifiers. CPT code 25110 should not be reported with other codes that describe excisions of different anatomical sites or lesions.

8. Historical information

CPT code 25110 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 25110

Five similar codes to CPT 25110 include:

• CPT 25111: Excision, lesion of tendon sheath, hand or finger(s)
• CPT 25112: Excision, lesion of tendon sheath, hand or finger(s); with release of constriction (e.g., trigger finger)
• CPT 25115: Excision, tumor, soft tissue of forearm and/or wrist area; subcutaneous
• CPT 25116: Excision, tumor, soft tissue of forearm and/or wrist area; subfascial (e.g., intramuscular)
• CPT 25118: Excision, tumor, soft tissue of forearm and/or wrist area; deep, subfascial (e.g., submuscular)

9. Examples

1. A patient undergoes excision of a lesion from the tendon sheath in the forearm to alleviate pain and restore function.
2. A provider performs excision of a lesion from the wrist tendon sheath to address a chronic inflammatory condition.
3. A patient with a tumor in the forearm tendon sheath undergoes excision to remove the abnormal growth.
4. A provider performs excision of a lesion from the wrist tendon sheath and repairs the resultant defect to restore normal anatomy.
5. A patient with a symptomatic lesion in the forearm tendon sheath undergoes excision to alleviate discomfort and improve function.
6. A provider performs excision of a lesion from the wrist tendon sheath and documents the procedure in the patient’s medical record.
7. A patient with a recurrent lesion in the forearm tendon sheath undergoes excision to prevent further complications.
8. A provider performs excision of a lesion from the wrist tendon sheath and provides post-operative care instructions to the patient.
9. A patient with a large lesion in the forearm tendon sheath undergoes excision to remove the abnormal tissue and improve symptoms.
10. A provider performs excision of a lesion from the wrist tendon sheath and ensures proper wound closure for optimal healing.