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The procedure described by CPT® Code 25100 refers to an arthrotomy of the wrist joint that includes a biopsy. An arthrotomy is a surgical procedure that involves making an incision into a joint to gain access for examination or treatment. In this case, the incision is typically made longitudinally along the midline or horizontally in accordance with Langer's lines, which are natural skin creases that help minimize scarring. The incision is performed on the dorsal (back) aspect of the wrist, and the specific approach may vary depending on the location of the pathology being addressed. During the procedure, full-thickness skin flaps are developed down to the extensor retinaculum, a fibrous band that holds the tendons of the wrist in place. Care is taken to protect important anatomical structures, including the superficial radial nerve, the dorsal sensory branch of the ulnar nerve, and various blood vessels. The retinaculum is then incised longitudinally over the third dorsal compartment to facilitate access to the wrist joint. If the surgical team needs to access the ulnar side of the wrist, the extensor pollicis longus tendon is retracted radially, and the fourth extensor compartment may be elevated subperiosteally, or the septum between the third and fourth compartments may be divided to create a flap over the ulna. Conversely, if access to the radial side is required, the extensor retinaculum is elevated off Lister's tubercle, and the second dorsal compartment is released. The procedure may also involve capsulotomy, where the dorsal radioulnar ligament is incised for ulnar capsulotomy, or the dorsal radiocarpal and intercarpal ligaments are incised for radial capsulotomy, following the natural alignment of their fibers. Once the wrist capsule is incised, the wrist joint is exposed, allowing for the biopsy to be performed using biopsy forceps to obtain a tissue sample. This procedure is critical for diagnosing various conditions affecting the wrist joint. After the necessary tissue samples are collected, the joint is flushed with sterile saline, and the surgical wound is closed in layers to promote proper healing.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 25100 is indicated for various conditions affecting the wrist joint that may require direct visualization and sampling of tissue. The following are common indications for performing an arthrotomy with biopsy:
The procedure for CPT® Code 25100 involves several detailed steps to ensure proper access to the wrist joint for biopsy. The following outlines the procedural steps:
After the arthrotomy and biopsy procedure, patients may require specific post-operative care to ensure proper recovery. It is important to monitor the surgical site for any signs of infection or complications. Patients are typically advised to keep the area clean and dry, and to follow any specific instructions provided by the healthcare provider regarding wound care. Pain management may be necessary, and patients may be prescribed analgesics as needed. Rehabilitation exercises may be recommended to restore mobility and strength in the wrist joint, depending on the extent of the procedure and the patient's overall condition. Follow-up appointments are essential to assess healing and to discuss the results of the biopsy.
| Short Descr | BIOPSY OF WRIST JOINT | Medium Descr | ARTHROTOMY WRIST JOINT WITH BIOPSY | Long Descr | Arthrotomy, wrist joint; with biopsy | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 0 - 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 | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 1 | CCS Clinical Classification | 159 - Other diagnostic procedures on musculoskeletal system |
| 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). | 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. | 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.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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) | SG | Ambulatory surgical center (asc) facility service | 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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| Pre-1990 | Added | Code added. |
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