Secondary repair of a flexor tendon or muscle in the forearm, performed after the initial acute injury has passed.

Verified May 8, 2026 · 6 sources ↓

Medicare: $607.90
Work RVU: 7.84
Global, days: 90
Region: Wrist

Drawn from CMSAAPCMdclarityAAOS

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Specify that this is a secondary (delayed) repair, not a primary acute repair — the operative note must establish the time interval from original injury.
Identify the specific tendon(s) or muscle(s) repaired by name and anatomic level in the forearm.
Document the surgical technique used: end-to-end suture, tendon graft, tendon transfer, or advancement.
If modifier 22 is appended, describe the specific factors increasing complexity — e.g., degree of scarring, adhesion takedown, tendon retraction distance.
Record pre-operative functional deficit (range of motion, grip, pinch strength) to support medical necessity.
Note laterality (left vs. right forearm) explicitly in both the operative note and the claim.

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 59 Distinct service 62 Co-surgeons 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 25263 covers delayed repair of a flexor tendon or muscle in the forearm — meaning the surgeon is operating after the window for primary repair has closed. This is a distinct clinical scenario from acute tendon repair (25260): the tissue has retracted, scarred, or degenerated, making the procedure technically more demanding than a fresh repair.

The code carries a 90-day global period. All routine post-op visits, wound checks, and splint/cast changes from the day before surgery through day 90 are bundled. Bill E/M services during that window only with modifier 24 (unrelated) or 25 (significant separate service on the same day as a minor procedure). If the surgeon decides on surgery at the pre-op E/M visit, append modifier 57 to that E/M — it's a major procedure with a 90-day global, so modifier 57 is required, not optional.

If additional tendon repairs are performed in the same session, modifier 51 applies to the secondary procedure(s). When repair complexity is substantially elevated — severe scar tissue, adhesion takedown, rerouting — modifier 22 requires detailed operative note documentation of why the work exceeded the typical case, not just a checkbox.

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 (7.84) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (18.2) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	7.84
Practice expense RVU	8.69
Malpractice RVU	1.67
Total RVU	18.2
Medicare national rate	$607.90
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	$607.90
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI A2) Ambulatory surgical center (freestanding)	$3,695.53

Common denial reasons

The recurring reasons claims for CPT 25263 get rejected.

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

Miscoding as 25260 (primary tendon repair) rather than 25263 (secondary/delayed repair) — payers audit the ICD-10 injury date against the procedure date.
Missing laterality on the claim — submit with LT or RT; Medicare and most commercial payers require it.
E/M visit during the 90-day global billed without modifier 24 or 25, triggering automatic bundling denial.
Modifier 22 submitted without an operative note that quantifies the additional work — payers reject unsupported complexity claims.
Bilateral repair billed as two line items without modifier 50, or billed with modifier 50 when payer requires separate line items with LT/RT — verify payer-specific bilateral billing rules before submitting.

Frequently asked questions

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

01What distinguishes 25263 from 25260?

25260 is primary (acute) flexor tendon repair performed shortly after the injury. 25263 is secondary repair — the original injury has had time to scar, retract, or partially heal before the surgeon intervenes. The ICD-10 diagnosis code and the operative note must support the delayed timeline, or payers will downcode to 25260.

02Can 25263 and 25260 be billed together on the same encounter?

Only if separate, distinct tendons are repaired — one meeting criteria for primary repair and another requiring secondary repair. Append modifier 59 or XS to the secondary code and document each tendon independently in the operative note.

03Does the 90-day global period reset if the patient returns for a related secondary procedure?

Yes. A staged or related return to the OR during the global period billed with modifier 58 resets the global clock from the date of the new procedure. An unplanned return for a related complication uses modifier 78 and does not reset the global.

04When should modifier 22 be used with 25263?

When operative complexity is substantially above typical — dense adhesion takedown, severe tendon retraction requiring graft, or extensive scar tissue excision. The operative note must describe the specific findings and extra work in detail. A generic statement like 'procedure was complex' will not survive audit.

05Is bilateral forearm tendon repair billable with modifier 50?

Bilateral repair of matching tendons in both forearms can be billed with modifier 50, but verify payer policy first. Medicare generally accepts modifier 50 on a single line. Many commercial payers want separate line items with LT and RT. Submitting in the wrong format triggers an automatic denial even when the clinical documentation is solid.

06Does 25263 require prior authorization?

Many commercial payers require prior authorization for forearm tendon repair. Authorization requirements vary by plan and are not standardized — confirm with each payer before scheduling. Lack of authorization is a leading non-clinical denial reason for this code.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the injury-to-repair interval, tendon name and anatomic level, surgical technique, and laterality directly from dictation — the four elements auditors check first when distinguishing 25263 from 25260. It also flags when the surgeon describes unusual scarring or retraction, prompting a modifier 22 documentation prompt before the note is finalized. That prevents the most common post-payment audit finding on delayed tendon repairs: an upbilled complexity modifier with no supporting narrative.

See how Mira captures CPT 25263 documentation