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The procedure described by CPT® Code 25065 refers to a biopsy of the soft tissue located in the forearm and/or wrist. A soft tissue biopsy is a medical procedure that involves the removal of a small sample of tissue from the soft tissues, which encompass various structures such as muscles, tendons, fat, blood vessels, lymph vessels, nerves, and the tissues surrounding joints. This procedure is typically performed to diagnose conditions affecting these tissues, such as infections, tumors, or other abnormalities. Prior to the biopsy, anesthesia—whether local, regional, or general—is administered based on the specific site and depth of the biopsy to ensure patient comfort. The area over the biopsy site is thoroughly cleansed to minimize the risk of infection. A careful incision is made to access the tissue, with particular attention given to protecting nearby blood vessels and nerves during the dissection process. Once the tissue sample is obtained, it is sent to a laboratory for histological evaluation, which is reported separately. After the sample is collected, the incision is closed using sutures. It is important to note that CPT® Code 25065 is specifically designated for superficial biopsies of masses or lesions found in the subcutaneous tissue, while CPT® Code 25066 is used for biopsies that require deeper dissection, such as those performed below the muscle fascia or within the muscle itself.
© Copyright 2025 Coding Ahead. All rights reserved.
The biopsy procedure described by CPT® Code 25065 is indicated for various conditions affecting the soft tissues of the forearm and/or wrist. The following are common indications for performing this procedure:
The procedure for a soft tissue biopsy of the forearm and/or wrist, as described by CPT® Code 25065, involves several key steps:
Following the biopsy procedure, patients are typically monitored for any immediate complications, such as excessive bleeding or signs of infection. Instructions for post-procedure care are provided, which may include keeping the biopsy site clean and dry, monitoring for any unusual symptoms, and managing pain with prescribed medications if necessary. Patients are advised to avoid strenuous activities that may stress the biopsy site during the initial healing period. Follow-up appointments may be scheduled to discuss the results of the histological evaluation and any further management based on the findings.
| Short Descr | BIOPSY FOREARM SOFT TISSUES | Medium Descr | BIOPSY SOFT TISSUE FOREARM&/WRIST SUPERFICIAL | Long Descr | Biopsy, soft tissue of forearm and/or wrist; superficial | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6B - Minor procedures - musculoskeletal | MUE | 2 | CCS Clinical Classification | 159 - Other diagnostic procedures on musculoskeletal system |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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