How To Use CPT Code 25116
CPT code 25116 describes the radical excision of bursa, synovia of the wrist, or forearm tendon sheaths to manage various disease conditions such as tenosynovitis, granulomas, rheumatoid arthritis, and others. 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 25116?
CPT code 25116 is used to describe the radical excision of bursa, synovia of the wrist, or forearm tendon sheaths. This procedure is performed to manage disease conditions such as tenosynovitis, granulomas, rheumatoid arthritis, and other conditions that affect the extensor tendons in the wrist or forearm. It involves the complete removal of inflamed or hypertrophied synovium, bursa, or tendon sheaths near the extensor tendons.
2. Official Description
The official description of CPT code 25116 is: ‘Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis) extensors, with or without transposition of dorsal retinaculum. For finger synovectomies, use 26145.’
3. Procedure
During the procedure described by CPT code 25116, the healthcare provider performs a radical excision of the bursa, synovia of the wrist, or forearm tendon sheaths. The patient is appropriately prepped and anesthetized before the procedure begins. The provider makes a longitudinal incision on the posterior side of the wrist joint to access the extensor tendons. The dorsal retinaculum is incised and elevated as flaps to expose the extensor tendons. Care is taken to protect blood vessels and nerves during the procedure. The provider thoroughly examines the extensor tendons and removes all inflamed or hypertrophied synovium, bursa, or tendon sheaths. After excision, the dorsal retinaculum is sutured back in its original place or at a new location to prevent further damage. The wound is then closed with sutures, and a drain may be placed if necessary.
4. Qualifying circumstances
CPT code 25116 is used for patients who require radical excision of bursa, synovia of the wrist, or forearm tendon sheaths due to conditions such as tenosynovitis, granulomas, rheumatoid arthritis, and others. The procedure is performed on the extensor tendons in the wrist or forearm. The patient must have a documented diagnosis that necessitates this surgical intervention. The procedure is typically performed by a qualified healthcare provider who has the necessary expertise and training in performing this specific procedure.
5. When to use CPT code 25116
CPT code 25116 should be used when a patient requires a radical excision of bursa, synovia of the wrist, or forearm tendon sheaths to manage conditions such as tenosynovitis, granulomas, rheumatoid arthritis, and others. This code should be used when the procedure is performed on the extensor tendons in the wrist or forearm. It is important to ensure that the documentation supports the medical necessity of the procedure and that the patient’s diagnosis aligns with the conditions that warrant this surgical intervention.
6. Documentation requirements
To support a claim for CPT code 25116, the healthcare provider must document the following information:
- Patient’s diagnosis necessitating the radical excision
- Details of the procedure performed, including the specific structures excised
- Date of the procedure
- Start and end time of the procedure
- Any additional procedures or interventions performed during the same session
- Any complications or unexpected findings
- Signature of the healthcare provider performing the procedure
7. Billing guidelines
When billing for CPT code 25116, it is important to ensure that the documentation supports the medical necessity of the procedure and that the patient’s diagnosis aligns with the conditions that warrant this surgical intervention. It is also important to follow the specific guidelines provided by the payer regarding the use of this code and any additional documentation requirements. It is recommended to review the payer’s policies and guidelines to ensure accurate and appropriate billing for this procedure.
8. Historical information
CPT code 25116 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 25116
There are several similar codes to CPT code 25116 that are used to describe related procedures. These include:
- CPT 25111: Excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis) flexors, with or without transposition of palmaris longus
- CPT 25112: Excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis) flexors, with or without transposition of palmaris longus; with tenolysis
- CPT 25115: Excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis) flexors, with or without transposition of palmaris longus; with synovectomy
- CPT 25118: Excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis) flexors, with or without transposition of palmaris longus; with tenolysis and synovectomy
- CPT 25145: Excision, tumor, soft tissue of forearm and/or wrist area; subcutaneous
9. Examples
- A patient with tenosynovitis undergoes a radical excision of bursa and synovia of the wrist extensors using CPT code
