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The procedure described by CPT® Code 25110 involves the excision of a lesion located within the tendon sheath of the forearm and/or wrist. In this surgical intervention, the physician begins by making an incision in the skin directly over the affected flexor or extensor tendon. This incision allows access to the underlying structures. Once the skin is incised, the physician carefully retracts the overlying tissue to expose the tendon. The next critical step involves identifying the lesion within the tendon sheath. The physician meticulously dissects the lesion away from the surrounding healthy tissue to ensure complete removal. This excision is performed with precision to minimize damage to adjacent structures. After the lesion is excised, it is sent for pathology evaluation to determine the nature of the tissue. Finally, the surgical wound is closed in layers, which is essential for proper healing and to reduce the risk of complications such as infection or scarring.
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The excision of a lesion of the tendon sheath in the forearm and/or wrist is typically indicated for various conditions that may affect the tendon sheath. These indications may include:
The procedure for excising a lesion of the tendon sheath involves several key steps, which are detailed as follows:
After the excision of the tendon sheath lesion, post-procedure care is essential for recovery. Patients may be advised to rest the affected area and avoid strenuous activities that could stress the wrist or forearm. Pain management may be necessary, and the physician may prescribe analgesics to alleviate discomfort. Follow-up appointments are typically scheduled to monitor the healing process and to review the pathology results. Patients should also be instructed on proper wound care to prevent infection and ensure optimal healing. Rehabilitation exercises may be recommended once the initial healing has occurred to restore function and strength to the affected tendon.
| Short Descr | REMOVE WRIST TENDON LESION | Medium Descr | EXCISION LESION TENDON SHEATH FOREARM&/WRIST | Long Descr | Excision, lesion of tendon sheath, forearm and/or wrist | 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) | 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 | 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 | 2 | CCS Clinical Classification | 160 - Other therapeutic procedures on muscles and tendons |
| 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | F7 | Right hand, third digit | F8 | Right hand, fourth digit | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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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