Surgical excision of a deep lesion — such as a ganglion cyst or tenosynovial mass — arising from deep structures of the wrist or forearm, requiring dissection beyond superficial tissue layers.

Verified May 8, 2026 · 6 sources ↓

Medicare: $571.16
Total RVUs: 17.1
Global, days: 90
Region: Wrist

Drawn from CMSAAPCMdclarity

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 6 cited references ↓

Operative note must specify depth of dissection — confirm lesion arose from deep structures, not subcutaneous tissue
Identify the anatomic origin of the lesion by name (e.g., dorsal radiocarpal joint capsule, flexor tendon sheath, volar wrist ligament)
Document incision location and approach in detail — avoid 'standard approach' language that audit teams flag
Confirm pre-op imaging or clinical findings that established the lesion as deep/subfascial rather than superficial
If billing with a concurrent procedure (e.g., 25320 or 29844), document separate incision site and clinical rationale for each distinct procedure
Pathology specimen submission note or gross description supports medical necessity and confirms excision was performed

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 25 Significant separate E/M 51 Multiple procedures 52 Reduced services 59 Distinct service 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 25116 covers open excision of a deep-seated lesion of the wrist or forearm — most commonly a deep ganglion cyst or tenosynovial mass requiring dissection through deeper anatomic layers. This distinguishes it from 25112, which addresses recurrent ganglion cysts of the wrist, and from 25111, which covers initial dorsal wrist ganglion excision. The depth of dissection and the specific anatomic origin of the lesion drive the code selection here; superficial excisions of the forearm or wrist skin and subcutaneous tissue fall under different codes entirely.

The 90-day global period means that any routine post-op visits, wound checks, and suture removals through day 90 are bundled. Unrelated E/M services in that window need modifier 24; a separately identifiable E/M on the day of surgery needs modifier 25. NCCI edits bundle 25115 into 25116 when performed through the same incision — a separate incision is required to support modifier 59 (use XS from the preferred set) and break that bundle. Payers including Aetna apply their own edits beyond NCCI; Aetna has denied 25116 billed same-day with 25320, arguing synovectomy is included in the wrist reconstruction code. Document incision site, depth, and anatomic origin of the lesion explicitly to defend separate billing.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	7.37
Practice expense RVU	8.32
Malpractice RVU	1.41
Total RVU	17.1
Medicare national rate	$571.16
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$571.16
HOPD (APC 5113) Hospital outpatient department	$3,342.87
ASC (PI A2) Ambulatory surgical center (freestanding)	$1,644.87

Common denial reasons

The recurring reasons claims for CPT 25116 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Bundling denial when billed same-day with 25320 — payers argue synovectomy is included; requires separate incision documentation and modifier XS or 59
Code-level downgrade to 25111 or 25112 when operative note fails to establish deep anatomic origin of the lesion
Missing or insufficient modifier when 25115 is billed on the same claim through the same incision — NCCI bundles 25115 into 25116 without a valid modifier
Payer-specific edits (notably Aetna) that differ from CMS NCCI rules, causing denials even when Medicare would allow the claim with a modifier
Lack of pre-operative or intraoperative documentation confirming depth, leading to medical necessity denial

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01How does 25116 differ from 25111 and 25112?

25111 covers initial excision of a dorsal wrist ganglion; 25112 is for a recurrent dorsal wrist ganglion. 25116 is used when the lesion is deep — arising from deep joint structures or tendon sheaths — and requires dissection beyond superficial layers. Lesion depth and anatomic origin are the deciding factors, not lesion size.

02Can I bill 25116 and 25115 on the same day?

NCCI bundles 25115 into 25116 when performed through the same incision. If a separate incision was used and the operative note documents it clearly, modifier 59 (or XS for a distinct anatomic site) can break the bundle. Same-incision cases will not survive an appeal.

03What if 25116 is billed same-day with 25320?

25320 (wrist reconstruction) includes synovectomy in its descriptor, so payers — Aetna in particular — have denied 25116 billed concurrently. If both were performed through separate incisions for distinct pathology, document that explicitly and appeal with the operative report. Some payers will not move off this denial regardless of modifier.

04Does CPT 25116 carry a global period?

Yes — 90-day global. Routine post-op visits, wound care, and suture removal through day 90 are bundled. Bill unrelated services with modifier 24; a separately identifiable same-day E/M needs modifier 25.

05When is modifier 22 appropriate for 25116?

Use modifier 22 when operative complexity was substantially greater than typical — for example, dense adhesions from prior surgery, aberrant anatomy, or significantly prolonged operative time. The operative note must quantify the additional work; a vague reference to 'difficulty' won't hold up on review.

06Should I append LT or RT when billing 25116?

Yes. Always lateralize with LT or RT. Missing laterality is a common clean-claim failure and can trigger a request for medical records before payment.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the anatomic origin of the lesion, depth of dissection, incision location, and approach from the surgeon's dictation — and flags when the operative note lacks language distinguishing the lesion as deep-seated versus subcutaneous. That prevents the most common audit trigger: a note that describes a deep excision but reads like a superficial one, giving payers grounds to downcode to 25111 or deny outright.

See how Mira captures CPT 25116 documentation