Surgical removal of a flexor or extensor tendon from the forearm or wrist, billed per tendon excised.

Verified May 8, 2026 · 5 sources ↓

Medicare: $506.02
Work RVU: 6.77
Global, days: 90
Region: Wrist

Drawn from AAPCEmednyCMSNIH

Documentation requirements

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

Source · Editorial brief grounded in 5 cited references ↓

Identify the specific tendon(s) excised — flexor or extensor — by name and anatomic location in the operative note.
State the surgical indication: tendon damage, anomalous structure, tenosynovitis, or other pathology necessitating excision rather than repair.
Document why excision was chosen over repair or transfer, especially if the tendon was functional pre-operatively.
Record the number of tendons excised to support multiple units if billing 25109 more than once per session.
Specify laterality (left, right, or bilateral) in both the diagnosis and operative note.
If performed concurrently with carpal tunnel release, the operative note must clearly delineate each procedure as a distinct surgical step with its own objective.

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 57 Decision for surgery 58 Staged or related 59 Distinct service 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 5 cited references ↓

CPT 25109 covers complete or partial surgical excision of a flexor or extensor tendon in the forearm or wrist. The code is tendon-specific: if multiple tendons are excised in the same session, each one supports a separate unit of 25109. Common indications include irreparably damaged tendons from chronic tenosynovitis, trauma, or anomalous structures (e.g., palmaris profundus, palmaris tertius) causing compressive pathology such as carpal tunnel syndrome.

The 90-day global period means all routine follow-up through day 90 is bundled. Postoperative visits for unrelated conditions require modifier 24; a separately identifiable E/M on the day of surgery requires modifier 25. If a second unrelated procedure falls within the global window, append modifier 79. A related return to the OR — for example, to address a wound complication — takes modifier 78.

When 25109 is billed alongside carpal tunnel release (64721), document clearly that the tendon excision was a distinct, necessary procedure separate from the nerve decompression. Auditors flag operative notes that describe only a single surgical objective when two codes are billed. Laterality modifiers LT and RT are required by most payers; bilateral cases use modifier 50 unless payer policy requires separate line items.

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 (6.77) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (15.15) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	6.77
Practice expense RVU	7.09
Malpractice RVU	1.29
Total RVU	15.15
Medicare national rate	$506.02
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	$506.02
HOPD (APC 5113) Hospital outpatient department	$3,342.87
ASC (PI G2) Ambulatory surgical center (freestanding)	$1,644.87

Common denial reasons

The recurring reasons claims for CPT 25109 get rejected.

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

Missing laterality modifier (LT or RT) — most Medicare contractors and commercial payers require it.
Bundling into a same-session carpal tunnel release (64721) when the operative note fails to distinguish the tendon excision as a separate, necessary procedure.
Insufficient medical necessity documentation — no pathology named or no explanation of why excision was required instead of repair.
Multiple units of 25109 denied when the note does not name each tendon individually to justify the additional units.
Global period conflict — follow-up visits billed without modifier 24 when the patient is still within the 90-day global of a prior procedure.

Frequently asked questions

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

01Can I bill 25109 twice if two tendons are excised in the same session?

Yes. The descriptor specifies 'each' tendon. Bill one unit of 25109 per tendon excised, with modifier 51 on the second unit. The operative note must name each tendon individually.

02Is 25109 bundled into carpal tunnel release (64721)?

Not automatically, but payers scrutinize this combination. If the tendon excision was a distinct step with its own indication — such as an anomalous palmaris profundus compressing the median nerve — document it separately and append modifier 59 or XS to 25109 to bypass the NCCI edit if one applies.

03What modifier is needed when 25109 is performed bilaterally?

Use modifier 50 for a bilateral procedure billed on a single line, or bill LT and RT on separate lines depending on payer preference. Confirm with the payer before defaulting to one method.

04Does the 90-day global include tendon-specific rehabilitation or therapy referrals?

The global covers the surgeon's routine post-op E/M visits, wound care, and dressing changes. Occupational or physical therapy billed by a separate provider is not bundled into the surgeon's global. If the surgeon provides the therapy personally, that may be bundled — confirm with payer policy.

05How does 25109 differ from 25110 and 25115?

25109 is excision of the tendon itself. 25110 is excision of a lesion of the tendon sheath — the tendon remains. 25115 is radical excision of bursa or synovium of flexor tendon sheaths, typically for granulomatous disease or rheumatoid arthritis. Code choice hinges on what was removed and why.

06What diagnosis codes pair with 25109?

Common ICD-10 pairings include M65.x (synovitis and tenosynovitis), M66.x (spontaneous tendon rupture), Q68.8 (anomalous congenital musculotendinous structure), and S56.x or S66.x traumatic tendon injury codes depending on etiology. Specificity to tendon type and laterality is required.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the tendon name, type (flexor vs. extensor), anatomic location within the forearm or wrist, surgical indication, and the extent of excision from dictation. When multiple tendons are removed, the scribe logs each separately so coders can support individual units of 25109. If a concurrent procedure is dictated — such as carpal tunnel release — the scribe flags it for modifier and bundling review, preventing automatic downcoding from a vague operative note.

See how Mira captures CPT 25109 documentation