What is CPT code 25000?
CPT code 25000, as defined by the American Medical Association’s Current Procedural Terminology, describes the incision of a wrist tendon sheath specifically performed to release contracture or relieve pressure within the extensor tendon compartment. Orthopedic surgeons and hand specialists typically perform this initial procedure to treat conditions such as De Quervain’s tenosynovitis, tendonitis, or other disorders causing restricted movement and pain. The procedure involves surgically opening the tendon sheath to decompress the affected extensor tendon. This CPT code covers all usual components performed during the surgery, including local anesthesia, incision, tendon sheath release, and routine postoperative care within the global postoperative period.
What is tendon sheath incision of the forearm/wrist?
A tendon sheath incision of the wrist involves surgically opening the sheath surrounding an extensor tendon to relieve pressure and restore normal tendon movement. This procedure is typically performed when inflammation, swelling, or thickening of the sheath restricts tendon motion, causing pain and limited functionality. Conditions such as De Quervain’s tenosynovitis commonly require this intervention to alleviate symptoms when conservative measures have partially reduced discomfort but failed to fully resolve the issue.
CPT code 25000 documentation requirements
Accurate and detailed documentation ensures compliance with medical coding standards and supports proper billing.
Diagnosis clearly documented
The medical record must clearly state the diagnosis justifying the procedure, such as De Quervain’s tenosynovitis or other relevant tendon disorders. This ensures accurate billing and supports the medical necessity of the incision.
Anatomical site and tendon sheath involved
Documentation must specify the precise anatomical location and clearly identify which extensor tendon sheath was addressed during the initial procedure. Specify laterality (left or right).
Description of incision and structures released
Clearly describe the incision technique, the structures encountered, and the extent of the tendon sheath released. This detailed description is essential for accurate CPT coding.
Pathological findings
Include details about any pathology encountered during the procedure, such as thickened retinaculum or fluid collection within the tendon sheath, and whether these conditions were fully or partially reduced.
Postoperative instructions and wound closure
Record clear postoperative instructions provided to the patient, including wound care, activity restrictions, and follow-up recommendations. Document wound closure methods to complete surgical documentation.
Neurovascular structures
The operative report should note if any neurovascular structures were encountered or impacted during surgery, enhancing clarity and completeness of the medical record.
CPT code 25000 billing guidelines
Following these billing guidelines will help ensure accurate reimbursement and adherence to correct coding practices.
Report per surgical site
CPT 25000 should be billed once per operative site per surgical session. Use the following modifiers as appropriate: modifier -LT (left), -RT (right), or modifier -59 for multiple procedures performed at separate sites during the same surgical session.
Do not report with tendon repair unless separate
Avoid billing CPT 25000 with tendon repair codes unless clearly documented as a distinct and unrelated procedure performed during a separate encounter by the same physician or a separate practitioner.
Local anesthesia included
Local anesthesia administered by the same physician performing the incision is considered integral and included within the global surgical package. It should not be billed separately.
Bundled into global surgical package
CPT 25000 is bundled with typical postoperative care provided during the standard postoperative period. Only billable once per operative site per session unless multiple, unrelated procedures are clearly documented.
Verify payer rules
Always verify specific payer rules and medical coding guidelines to ensure accurate billing and compliance, particularly when performing multiple procedures during the same surgical session.
Other relevant CPT codes
- 25001 – Incision of tendon sheath with drainage
- 26055 – Release of trigger finger
- 25115 – Excision of tendon sheath or ganglion
- 25118 – Synovectomy of extensor tendon sheath, wrist
- 25290 – Tenotomy, flexor tendon, forearm/wrist, single
Frequently asked questions
Typically, CPT 25000 and 26055 should not be billed together for the same tendon sheath during the same surgical session, as they represent overlapping services. You can bill these specific codes together only if they clearly represent separate anatomical locations or distinct encounters.
No, ultrasound or other imaging guidance services performed is not included in CPT 25000. You may separately bill imaging guidance if clearly documented as medically necessary and distinct from usual components of the procedure.
CPT 25000 involves incision and release of the extensor tendon sheath at the wrist to relieve pressure. CPT 25118 describes a synovectomy (removal of inflamed synovial tissue) of the extensor tendon sheath at the wrist, representing a more extensive procedure typically performed when inflammation significantly affects tendon function.
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