Surgical removal of a deeply embedded foreign body from the forearm requiring open exploration beyond simple superficial retrieval.

Verified May 8, 2026 · 6 sources ↓

Medicare: $408.16
Work RVU: 5.18
Global, days: 90
Region: Wrist

Drawn from CMSAAOSAAPCAoassn

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 identify the depth of dissection — subcutaneous, fascial, or intramuscular — not just 'deep' removal
Describe the foreign body by type and size (e.g., metal fragment, glass shard, retained suture hardware) and exact anatomical location within the forearm
Preoperative imaging (X-ray, fluoroscopy, or ultrasound) identifying the foreign body's location should be referenced in the note
Document any neurovascular structures encountered or protected during dissection, especially given proximity to radial and ulnar vessels and nerves
If the foreign body was not retrieved, document the full exploration and negative finding explicitly — do not leave this implied
Laterality must be specified (left vs. right) to support LT or RT modifier assignment

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 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

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 25248 covers open surgical removal of a foreign body lodged deep within the forearm — think retained hardware fragments, shrapnel, glass, or industrial debris that cannot be retrieved at the bedside or through simple incision. The depth and dissection required distinguish this from superficial foreign body removal codes; expect documented exploration through subcutaneous tissue, fascia, or muscle to reach the object.

This code carries a 90-day global period. All routine follow-up care — wound checks, suture removal, dressing changes — is bundled through day 90. Any unrelated evaluation during that window requires modifier 24 on the E/M code. If you're billing a decision-for-surgery visit the day before or day of the procedure, append modifier 57 to that E/M.

If the surgeon explores the forearm but does not locate or retrieve a foreign body, 25248 is not supportable as billed. Some coders append modifier 52 in that scenario; document the full exploration attempt and the negative finding explicitly in the operative note. Imaging confirmation of the foreign body's presence before surgery strengthens medical necessity and reduces audit exposure.

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 (5.18) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (12.22) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	5.18
Practice expense RVU	5.92
Malpractice RVU	1.12
Total RVU	12.22
Medicare national rate	$408.16
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	$408.16
HOPD (APC 5112) Hospital outpatient department	$1,642.82
ASC (PI A2) Ambulatory surgical center (freestanding)	$872.87

Common denial reasons

The recurring reasons claims for CPT 25248 get rejected.

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

Lack of imaging documentation to confirm preoperative foreign body presence, flagging medical necessity
Operative note describes only superficial retrieval without documentation of depth of dissection, suggesting a lower-complexity code was more appropriate
Modifier 52 omitted when exploration was performed but the foreign body was not found or removed
Missing laterality modifier (LT or RT) causing claim edits or rejection on facility and payer claims
Global period conflicts when post-op E/M visits are billed without modifier 24 for unrelated conditions within the 90-day window

Frequently asked questions

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

01What separates 25248 from a simple superficial foreign body removal?

25248 is for deep foreign body removal requiring dissection below the superficial fascia. If the object is retrieved through a simple skin incision without deeper dissection, a lower-complexity integumentary foreign body code is more appropriate. Your operative note must document the tissue layers traversed.

02Can I bill 25248 if we explored but didn't find the foreign body?

The code as written describes removal, not exploration alone. If no foreign body was retrieved, some coders append modifier 52 to indicate a reduced service. Document the full exploration, all layers dissected, and the negative finding in detail. Some payers will not reimburse 25248 at all without a retrieved object; verify payer policy before submitting.

03Is intraoperative fluoroscopy billable separately with 25248?

Fluoroscopic guidance used intraoperatively to locate the foreign body is a separately reportable service. Report the appropriate fluoroscopy code with modifier 26 if you're billing the professional component only. Check NCCI edits for your payer to confirm no bundling restriction applies.

04What modifiers apply if I perform 25248 during the global period of a prior forearm procedure?

If the foreign body removal is unrelated to the original procedure, use modifier 79. If it's related (e.g., retained hardware from the index surgery), use modifier 78. Do not invert these — 78 is for related, unplanned return to the OR; 79 is for a truly unrelated procedure during an active global period.

05Does the 90-day global period affect billing if the patient returns for a wound complication?

Routine wound care and follow-up are bundled through day 90. If the patient returns with a complication requiring a return to the OR — such as infection requiring debridement — bill the debridement code with modifier 78 if related to the original procedure. For unrelated conditions managed in office, append modifier 24 to the E/M code.

06Should I use LT or RT with 25248?

Yes. Always append LT or RT to lateralize the procedure. Some payers require laterality modifiers for all extremity codes; omitting them is a common clean-claim failure point, especially under OPPS and ASC billing.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the depth of dissection, the anatomical layer reached (subcutaneous, fascial, intramuscular), a description of the foreign body retrieved including material and size, any neurovascular structures encountered, and the confirmed laterality — all from the surgeon's dictation. This prevents the most common audit flag on 25248: an operative note that documents an incision without establishing that dissection was deep enough to support the code, or that fails to document the retrieved object itself.

See how Mira captures CPT 25248 documentation