How To Use CPT Code 25115

CPT code 25115 describes the radical excision of bursa, synovia of the wrist, or forearm tendon sheaths. 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 25115?

CPT 25115 is a code used to describe the radical excision of bursa, synovia of the wrist, or forearm tendon sheaths. This procedure involves the extensive removal of diseased tissue, including bursa, synovium, and/or tendon anatomy. It is typically performed to treat conditions such as tenosynovitis, fungal infections, tuberculosis, granulomas, and rheumatoid arthritis affecting the flexors of the wrist or forearm.

2. Official Description

The official description of CPT code 25115 is: ‘Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis) flexors.’

3. Procedure

The procedure for CPT code 25115 involves the following steps:

1. After administering anesthesia and preparing and draping the site, the provider makes a standard mid-palm incision.
2. The incision is extended to gain access to the underlying structures.
3. The provider divides and reflects the subcutaneous and fascial layers to further expose the underlying carpal tunnel ligament.
4. Hypertrophic synovium, diseased bursa, or tendon tissue is extensively excised, involving the entire area of concern.
5. The excision is usually performed in an en bloc fashion.
6. The provider carefully checks the wound for any residual diseased tissue.
7. Necessary repairs are made to keep the residual tissues in place.
8. The wound is closed in layers in an aseptic manner.

4. Qualifying circumstances

CPT code 25115 is typically used for patients with conditions such as tenosynovitis, fungal infections, tuberculosis, granulomas, or rheumatoid arthritis affecting the flexors of the wrist or forearm. The procedure involves the radical excision of bursa, synovia, and/or tendon sheaths. It is important to note that the specific qualifying circumstances may vary depending on the patient’s individual condition and the provider’s clinical judgment.

5. When to use CPT code 25115

CPT code 25115 should be used when the provider performs the radical excision of bursa, synovia of the wrist, or forearm tendon sheaths. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure does not involve the excision of bursa, synovia, or tendon sheaths, a different CPT code may be more appropriate.

6. Documentation requirements

To support a claim for CPT code 25115, the provider must document the following information:

• Patient’s diagnosis and the need for radical excision of bursa, synovia, or tendon sheaths
• Details of the procedure performed, including the specific structures involved
• Date of the procedure
• Start and end time of the procedure
• Any repairs made during the procedure
• Wound closure technique used
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 25115, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The provider should also follow any additional billing guidelines provided by the payer. It is important to note that CPT code 25115 should not be reported with other codes that describe similar procedures or services, unless there are distinct and separate anatomical sites involved.

8. Historical information

CPT code 25115 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Similar codes to CPT 25115

There are several similar codes to CPT code 25115 that describe excision procedures on the forearm and wrist. These include:

• CPT 25065: Excision, tumor, soft tissue of forearm and/or wrist area; subcutaneous
• CPT 25066: Excision, tumor, soft tissue of forearm and/or wrist area; subfascial (eg, intramuscular)
• CPT 25075: Excision, tumor, soft tissue of forearm and/or wrist area; deep (eg, intramuscular, intrafascial, or subfascial)
• CPT 25210: Excision, tumor, soft tissue of forearm and/or wrist area; subperiosteal
• CPT 25240: Excision, tumor, soft tissue of forearm and/or wrist area; radical, deep (eg, intramuscular, intrafascial, or subfascial)

9. Examples

1. A patient with tenosynovitis undergoes radical excision of the diseased tendon sheaths in their wrist.
2. A patient with rheumatoid arthritis requires the radical excision of hypertrophic synovium in their forearm.
3. A patient with a fungal infection in their wrist undergoes the radical excision of the affected bursa.
4. A patient with granulomas affecting the flexors of their forearm undergoes radical excision of the diseased tissue.
5. A patient with tuberculosis in their wrist requires the radical excision of the affected synovia.
6. A patient with rheumatoid arthritis affecting the flexors of their wrist undergoes radical excision of the diseased tendon sheaths.
7. A patient with tenosynovitis in their forearm requires the radical excision of the affected bursa and synovium.
8. A patient with a fungal infection in their wrist undergoes radical excision of the diseased tendon sheaths.
9. A patient with granulomas affecting the flexors of their forearm requires the radical excision of the affected synovia and bursa.