Surgical division or revision of the sternocleidomastoid muscle in the neck, typically performed to correct torticollis, with cast application to maintain neck position post-operatively.

Verified May 8, 2026 · 5 sources ↓

Medicare: $515.38
Work RVU: 7.01
Global, days: 90
Region: Other

Drawn from CMSAAPCWorkerscomp

Documentation requirements

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

Source · Editorial brief grounded in 5 cited references ↓

Diagnosis of torticollis with clinical description of head tilt, direction, and duration — ICD-10 must support medical necessity
Operative note identifying the sternocleidomastoid muscle by name and describing the specific surgical technique used (division, lengthening, or revision)
Documentation of cast or immobilizing device applied post-operatively, including type and positioning
Prior treatment history (conservative care, physical therapy, injections) to establish medical necessity for surgical intervention
If bilateral procedure performed, separate documentation of findings and work performed on each side of the neck

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 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 58 Staged or related 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 5 cited references ↓

CPT 21725 describes a surgical procedure in which the sternocleidomastoid (SCM) muscle is divided or revised to treat torticollis — a condition causing involuntary head tilt and neck muscle contracture. The surgeon releases or modifies the SCM, then applies an immobilizing cast or splint to hold the corrected neck position during healing. This is not a simple soft-tissue excision; it's a targeted neuromuscular correction with positional fixation.

The code falls under Repair, Revision, and/or Reconstruction Procedures on the Neck (Soft Tissues) and Thorax. It carries a 90-day global period, meaning all routine post-operative management — including cast checks, wound care, and follow-up visits related to the SCM revision — is bundled through day 90. Any E/M service for an unrelated condition during that window requires modifier 24.

This procedure is most often performed by plastic surgeons, otolaryngologists, or orthopedic surgeons with head-and-neck expertise. It can be performed in a hospital outpatient department or ASC setting; site of service affects facility payment significantly (see the Site of Service comparison). Workers' compensation payers, including New Mexico's 2026 fee schedule, carry their own allowables for this code distinct from Medicare rates.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (7.01) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (15.43) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	7.01
Practice expense RVU	6.94
Malpractice RVU	1.48
Total RVU	15.43
Medicare national rate	$515.38
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	$515.38
HOPD (APC 5071) Hospital outpatient department	$723.47
ASC (PI A2) Ambulatory surgical center (freestanding)	$388.55

Common denial reasons

The recurring reasons claims for CPT 21725 get rejected.

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

Medical necessity not established — missing documentation of failed conservative treatment prior to surgical referral
Operative note lacks specificity on which muscle was addressed or the surgical technique performed
Post-operative E/M visits billed without modifier 24 during the 90-day global period, triggering automatic bundling denial
ICD-10 diagnosis code does not map to torticollis or an accepted indication for SCM revision
Bilateral procedure billed without modifier 50, or billed as two separate line items without appropriate modifier distinction

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01What is the global period for CPT 21725?

90 days. All routine post-op visits, wound care, and cast management related to the SCM revision are bundled from the surgery date through day 90. Unrelated E/M services in that window need modifier 24.

02Can 21725 be billed bilaterally?

Yes. If the surgeon revises the SCM on both sides during the same operative session, append modifier 50. Some payers require LT and RT on separate lines instead — verify payer preference before submitting.

03What ICD-10 codes support 21725?

Torticollis (M43.6) is the primary indication. Congenital torticollis (Q68.0) applies for pediatric cases. The diagnosis must be documented clinically in the record, not just listed on the claim.

04Is 21725 typically performed in an ASC or hospital outpatient setting?

Both settings are viable. ASC payment is lower than HOPD payment under CMS — see the Site of Service comparison on this page. For workers' comp cases, payer-specific fee schedules (e.g., New Mexico 2026 WC) apply instead of Medicare rates.

05Does 21725 require pre-authorization?

Most commercial payers and workers' comp carriers require prior authorization for elective surgical soft-tissue procedures of the neck. Confirm with each payer. Medicare does not require pre-auth, but does require documented medical necessity.

06If a complication requires a return to the OR during the global period, what modifier applies?

Modifier 78 if the return procedure is related to the original SCM revision. Modifier 79 if it's unrelated. Do not swap these — inverting 78 and 79 is a common audit finding and can trigger recoupment.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the muscle name (sternocleidomastoid), the surgical technique (division, lengthening, or revision), the indication (torticollis with documented head tilt direction), and the post-operative immobilization method from dictation. This prevents the most common audit flag for 21725: operative notes that reference 'neck muscle' generically without naming the SCM or specifying what was done to it.

See how Mira captures CPT 21725 documentation