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2025 CPT code 20525

Removal of foreign body in muscle or tendon sheath, deep or complicated.

Use 20525 when the removal is deep or complicated due to factors such as location, the presence of infection, or extensive dissection required. Do not use this code for simple foreign body removals or removals from other anatomical locations with specific CPT codes.

Modifiers may be applicable to indicate specific circumstances, such as increased procedural services (22), reduced services (52), or multiple procedures (51). Refer to CPT modifier guidelines for appropriate usage.

Medical necessity is established by the presence of a foreign body causing symptoms or posing a risk of complications such as infection, pain, or functional impairment. Documentation should clearly support the need for surgical removal.

The physician is responsible for the entire procedure, including prepping the patient, administering anesthesia, making the incision, dissecting the tissue, locating and removing the foreign body, cleaning the wound, closing the incision or packing the wound if necessary, and providing post-operative care.

IMPORTANT:For simple removal of a foreign body from the muscle or tendon sheath, use 20520. For removal of foreign bodies from other anatomical locations, refer to specific CPT codes for those areas. If no specific code exists, 20520 or 20525 may be used, but specific codes are preferred when available.

In simple words: The doctor removes a foreign object (like a splinter, glass, or metal) that is stuck deep in your muscle or the lining around your tendon. This requires a small surgery where the doctor makes a cut to reach the object and carefully removes it.

The physician removes a foreign body lodged deeply within the muscle or tendon sheath. This involves a surgical incision, dissection to reach the affected area, and removal of the foreign object. The complexity may stem from the depth of the foreign body, the presence of infection, or the need for extensive dissection or removal of necrotic tissue. Closure of the incision, or packing if contaminated, follows the removal.

Example 1: A patient presents with a metal shard deeply embedded in their thigh muscle following an accident. The shard is located using radiographic imaging and removed through a surgical incision., A patient has a piece of glass embedded in the tendon sheath of their hand after punching through a window. The glass is deep and requires intricate dissection to remove without damaging the surrounding tendons., A patient with a wooden splinter lodged deep in their forearm experiences increasing pain and swelling, suggesting infection. The physician removes the splinter and necrotic tissue surrounding the infection.

Documentation should include details of the foreign body (type, size, location), the surgical approach used, the depth and complexity of the removal, any associated complications (e.g., infection), and the method of wound closure. Pre- and post-procedure imaging reports should also be included if used.

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