How To Use CPT Code 26116

CPT 26116 describes the excision of a subfascial tumor or vascular malformation from the soft tissue of the hand or finger, with a resection size of less than 1.5 cm. 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 26116?

CPT 26116 can be used to describe the excision of a subfascial tumor or vascular malformation from the soft tissue of the hand or finger, with a resection size of less than 1.5 cm. This code is used when the provider makes an incision in the hand or finger, dissects the tissue down to the subfascial level, and removes the lesion along with any surrounding soft tissue if necessary.

2. Official Description

The official description of CPT code 26116 is: ‘Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, intramuscular); less than 1.5 cm.’

3. Procedure

1. The provider preps and anesthetizes the patient appropriately.
2. An incision is made in the hand or finger over the tumor or vascular malformation.
3. The provider dissects the tissue down to the subfascial level to reach the lesion.
4. Arteries, nerves, and other structures are identified and protected.
5. The lesion is meticulously dissected from the adjacent tissues.
6. If necessary, some of the surrounding soft tissue may be removed.
7. The wound is irrigated and hemostasis is achieved.
8. The provider closes the skin and may place a drain if needed.

4. Qualifying circumstances

Patients eligible for CPT 26116 are those who require the excision of a subfascial tumor or vascular malformation from the soft tissue of the hand or finger, with a resection size of less than 1.5 cm. The procedure must be performed by a qualified provider and meet the specific criteria outlined in the code description.

5. When to use CPT code 26116

CPT code 26116 should be used when a provider performs the excision of a subfascial tumor or vascular malformation from the soft tissue of the hand or finger, with a resection size of less than 1.5 cm. This code should not be used for larger lesions, as there is a separate code for those cases (CPT 26113).

6. Documentation requirements

To support a claim for CPT 26116, the provider must document the following information:

• Patient’s diagnosis and the need for the excision
• Size of the lesion and its location
• Details of the procedure, including the incision, dissection, and removal of the lesion
• Any additional procedures performed, such as removal of surrounding soft tissue or placement of a drain
• Any complications or unexpected findings
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 26116, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the size of the lesion and any additional procedures performed. CPT code 26116 should not be reported with CPT codes 26113 or any other codes that are not directly related to the excision of a subfascial tumor or vascular malformation from the soft tissue of the hand or finger.

8. Historical information

CPT 26116 was added to the Current Procedural Terminology system on January 1, 1990. There have been two code changes since its addition, with the most recent change occurring on January 1, 2010.

9. Examples

1. A provider performs the excision of a 1 cm subfascial tumor from the soft tissue of a patient’s finger.
2. A patient undergoes the excision of a 1.2 cm vascular malformation from the subfascial layer of their hand.
3. A provider removes a 1.4 cm subfascial tumor from the soft tissue of a patient’s finger and also performs the excision of some surrounding soft tissue.
4. A patient requires the excision of a 1.3 cm vascular malformation from the subfascial layer of their hand, with repair of the wound.
5. A provider performs the excision of a 1.1 cm subfascial tumor from the soft tissue of a patient’s finger, with repair of the wound.
6. A patient undergoes the excision of a 1.5 cm vascular malformation from the subfascial layer of their hand, with repair of the wound.