Tenosynovitis, or swelling and inflammation of the tendon sheaths, is one of the most common orthopedic conditions in the USA. Out of every 100 people, two or three experience it due to constant strain on the fingers, wrist, and forearm. Another study suggests that women are 2.6 times more likely to be diagnosed with the condition than men. So, if the disease is highly prevalent and hinders daily living, what can be done to treat it?
The answer lies in CPT code 25000. This 5-digit code covers an orthopedic surgical procedure for the treatment of tenosynovitis, restoring the normal movement of the hand, wrist, fingers, and thumb.
Let’s explore CPT 25000 in detail, including its practical scenarios, applicable modifiers, and billing guidelines.
CPT Code 25000 – Description
The Current Procedural Terminology (CPT) code 25000 is part of the ‘Incision Procedures on the Forearm and Wrist’ range, as maintained by the American Medical Association (AMA). It reports an incision into the extensor tendon sheath of the wrist to relieve pressure, pain, and swelling. The procedure is typically performed to treat conditions like De Quervain’s tenosynovitis, which occurs when two tendons in the thumb become constricted because of their tendon sheath in the wrist. The condition is painful and affects the thumb’s movement.
The healthcare provider, usually an orthopedic surgeon in this case, makes a small incision near the base of the thumb to identify and reach the inflamed tendon sheath. He then cuts the sheath to release swollen tendons and let them glide freely. The incision is then closed with stitches, and a bandage or splint is applied to protect the wound.
Please note that this minor surgical procedure may require administering local or regional anesthetics. Also, the common cause of De Quervain’s tenosynovitis is the chronic overuse of the wrist.
Scenarios Where CPT Code 25000 is Applicable
Now that you understand what CPT code 25000 explains to the insurance payer, let’s look at some real-world examples where this code can be applied for accurate billing and rightful reimbursement.
A Diabetic Patient’s De Quervain’s Tenosynovitis is Treated Surgically
In the first example, we want you to think of a 40-year-old woman with diabetes who works at a daycare center, lifting and attending to babies and toddlers all day. Because her work involves overuse of the wrist, the tendon sheath becomes inflamed, restricting her tendons and affecting her grip and hand movement. Her orthopedist first tried to treat De Quervain’s tenosynovitis with corticosteroid injections, but because of her diabetes, the treatment proved to be ineffective.
Thereafter, he prepares her for a minor surgical procedure, which involves the incision of the extensor tendon sheath in the wrist. After the procedure, the orthopedic surgeon will bill the procedure with CPT code 25000 for clean claim submission and accurate reimbursement collection.
A Patient with Rheumatoid Arthritis is Surgically Treated for Tendon Release
Let’s consider another example where a tendon sheath incision was made to treat tendon contraction because of rheumatoid arthritis. Imagine a 65-year-old woman with arthritis visiting the orthopedist complaining of stiffness in her fingers and thumb. She is unable to stretch her fingers outwards or grip objects. Moreover, she complains of severe pain in her right thumb and wrist.
After some quick and simple examinations, like the Finkelstein/Eichhoff test, the orthopedist diagnoses her with tenosynovitis or inflamed and swollen tendon sheaths.
For immediate effect, he tells her to return for a minor procedure the next day, where he makes an incision in her right wrist’s tendon sheath to release the constrained tendons. The incision is closed with a couple of stitches, and she is sent home for recovery. The orthopedist bills the procedure with CPT code 25000 and submits the claim to the insurance payer.
Applicable Modifiers for CPT Code 25000
The following modifiers are most commonly appended with the CPT code 25000 to explain accurately the circumstances under which an incision procedure on the forearm and wrist was performed.
Modifier LT
Modifier LT is a location modifier. It explains to the insurance payer that the tendon sheath incision was performed on the left side of the body, in this case, on the left hand.
Modifier RT
Modifier RT also serves a similar purpose. It provides supplemental information to the insurance payer, explaining that the incision was performed on the right hand and wrist.
Please note that informational or location modifiers RT and LT are only appended with procedural codes for services performed on paired structures, e.g., the eyes, knees, lungs, arms, breasts, hands, etc.
Modifier 22
Modifier 22 is a pricing modifier with a significant effect on the reimbursement rate. It indicates that the procedure required more physical and mental effort than usual. Or that the otherwise ordinary procedure became complex or technically difficult due to unforeseen circumstances.
You can append modifier 22 with CPT code 25000 to collect reimbursement for your extra effort.
Modifier 50
Like modifiers RT and LT, 50 is also a location modifier and explains that the procedure was performed on both sides of the body (bilaterally). So, you should append modifier 50 with CPT code 25000 if the tendon sheath incision was performed on both forearms/wrists to relieve pressure.
Modifier 52
Modifier 52 also affects the reimbursement rate. It indicates that the procedure was partially reduced or eliminated at the healthcare provider’s discretion. However, it can only be appended with CPT code 25000 if the anesthesia was unplanned.
Modifier 52 will reduce the reimbursement rate by 50% of the allowed amount.
Modifier 59
You can append modifier 59 with CPT code 25000 to indicate that the two services are separately identifiable (and separately payable) if another distinct service was also performed on the same day as the tendon sheath incision. It will help you avoid “claim duplication” or “bundled payment”-related denials.
Some other modifiers that you can append with CPT code 25000 include:
| Applicable Modifier with CPT Code 25000 | Explanation |
|---|---|
| 51 | Indicates that the same provider performed multiple procedures (other than E/M services) during the same surgical session. |
| 76 | This modifier explains that the same physician repeated the procedure on the same patient on the same day. |
| 77 | It is appended to explain that another physician repeated the procedure on the same patient on the same day. |
| 78 | Indicates the same physician’s unplanned return to the operating room after an initial procedure and during the postoperative period. Used when the first and second procedures are related. |
| 79 | Explains that the same physician performed a second but unrelated procedure during the postoperative period of the first procedure. Here, the first and second procedures are distinct/unrelated. |
| XS | Explains that the procedure is distinct and separately billable because it was performed on a separate structure/organ. |
| XP | Explains that the procedure is distinct and separately billable because it was performed by a separate practitioner. |
| XE | Explains that the procedure is distinct and separately billable because it occurred during a separate encounter. |
| XU | Explains that the procedure is distinct and separately billable because its usual components do not overlap with the primary service. |
CPT Code 25000 – Billing & Reimbursement Guidelines
The insurance payer’s decision to approve or reject your claim request and the final reimbursement rate depends on your medical coding and billing accuracy. Even if you are 100% sure that CPT code 25000 accurately specifies the procedure you just performed on your patient, you must complement it with billing best practices to ensure a clean and compliant claim submission.
Here are a few billing and reimbursement guidelines you must follow to avoid claim denial.
Pair with the Accurate Diagnosis Code
Please understand that CPT code 25000 is diagnosis-dependent, and in many insurance payers’ and healthcare organizations’ handbooks, its code descriptor specifies De Quervain’s disease. For example, according to the American College of Surgeons and UnitedHealthcare booklets, code 25000 describes an “Incision, extensor tendon sheath, wrist (e.g., de Quervains disease)”.
Therefore, you must pair CPT code 25000 with the correct ICD-10 diagnosis code — usually M65.4 for De Quervain’s disease, to support the medical necessity of a tendon sheath incision.
Report with an Outpatient Surgery POS Code
An extensor tendon sheath incision, reported by CPT code 25000, is typically performed in an outpatient setting and lasts for about a few minutes to half an hour.
Hence, you should report it with the appropriate Place of Service (POS) code to justify that the surgery was performed in an outpatient setting. For example, use code 19 for an off-campus outpatient hospital, code 22 for an on-campus outpatient hospital, code 24 for an ambulatory surgical center (ASC), or code 11 for an office.
Provide Adequate Documentation
You must also maintain and submit complete and accurate documentation to explain the necessity of performing an extensor tendon sheath incision and your billed amount. For example, your documents must include imaging or physical examination reports like MRI or Finkelstein test to support tendon sheath swelling and inflammation (tenosynovitis) and its treatment.
Secondly, if the procedure was reduced, terminated, or became more complex, then your operative notes must highlight the accurate reasoning to support modifier usage.
Follow Payer-Specific Billing Rules
Billing and reimbursement guidelines vary from payer to payer. Whether it is Medicare, Medicaid, or any other commercial payer, each will have its own billing rules and reimbursement rates for CPT code 25000. For example, Medicare may reimburse orthopedic surgeons up to $443.69 for the incision of a tendon sheath. Whereas, Medi-Cal will pay a basic rate of up to $185.41.
Therefore, you must thoroughly read each payer’s contract and billing requirements before claim submission to ensure compliance and avoid denials.
Use Modifiers when Appropriate
You must also use the appropriate pricing, payment, and location modifiers when needed to provide supplemental information to the insurance payer and ensure rightful reimbursements.
You can refer to the ‘Applicable Modifiers for CPT Code 25000’ section above to familiarize yourself with the modifiers that are most frequently appended with CPT 25000. Note that missing or invalid modifiers often result in claim denials.
Summary
Before we tell you about the ultimate solution to cracking CPT code 25000, let’s revisit all that we learned in this guide. We told you that code 25000 reports the incision of an inflamed tendon sheath to release restricted tendons in the wrist.
Next, we gave two real-world examples where performing a tendon sheath incision becomes necessary, such as to treat rheumatoid arthritis and De Quervain’s disease. We also discussed some of the most frequently appended modifiers with CPT code 25000, such as modifiers LT, RT, 22, 50, 51, 52, and 59. Lastly, we informed you about the billing best practices that will justify your usage of CPT 25000 and ensure an accurate and speedy reimbursement collection.
Now, the easiest way to get your claim approved on the first attempt is to outsource medical coding and billing to professionals like MediBillMD. Their full-stack orthopedic billing services include CPT coding at the hands of AAPC-certified professional coders, guaranteeing a 98% clean claim rate.
