Total wrist arthroplasty replacing the distal radius and partial or entire carpus with prosthetic components

Verified May 8, 2026 · 7 sources ↓

Medicare: $1,051.79
Total RVUs: 31.49
Global, days: 90
Region: Wrist

Drawn from CMSAAPCFindacode

Documentation requirements

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

Source · Editorial brief grounded in 7 cited references ↓

Operative note must name the prosthetic system, manufacturer, model, and implant lot/serial number
Document extent of carpal resection — specify partial vs. complete carpus removed
Identify the surgical approach by name (dorsal, volar, or other) — notes that say 'standard approach' invite audit
Clinical justification for total wrist arthroplasty over wrist fusion (arthrodesis), including failure of conservative treatment
Preoperative imaging (X-ray, CT, or MRI) confirming joint destruction severity must be in the record
Document neurovascular status of the hand and wrist preoperatively and postoperatively
ICD-10 diagnosis code must match documented pathology — rheumatoid arthritis, post-traumatic arthritis, or osteoarthritis as applicable

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 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

CPT 25446 covers total wrist arthroplasty: resection of the distal radius and ulnar head combined with removal of part or all of the carpal bones, followed by implantation of a prosthetic wrist joint. The procedure addresses end-stage wrist destruction from severe osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis when conservative management and lesser salvage procedures have failed. The goal is pain relief and functional restoration of wrist motion.

This is a high-complexity reconstruction carrying a 90-day global period. All routine post-op visits, dressing changes, and splint adjustments through day 90 are bundled. Unrelated E/M visits in that window need modifier 24; a separate decision-for-surgery visit the day before or day of requires modifier 57. Intraoperative fluoroscopy, implant sizing, and closure are included — do not unbundle component steps.

Payer scrutiny is significant for this code. Document the specific prosthetic system implanted (manufacturer, model, lot number), the extent of carpal resection (partial vs. complete carpus), the approach used, and the clinical rationale for arthroplasty over arthrodesis. Failure to distinguish total wrist replacement from partial carpal resection or wrist fusion is the most common coding error in this region.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	16.87
Practice expense RVU	11.34
Malpractice RVU	3.28
Total RVU	31.49
Medicare national rate	$1,051.79
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	$1,051.79
HOPD (APC 5116) Hospital outpatient department	$17,913.59
ASC (PI J8) Ambulatory surgical center (freestanding)	$14,530.31

Common denial reasons

The recurring reasons claims for CPT 25446 get rejected.

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

Diagnosis code mismatch — billing a degenerative arthritis code when the record documents inflammatory or post-traumatic etiology
Missing implant documentation — payers and auditors require manufacturer and model details; absence triggers medical necessity review
Unbundling distal radius resection or carpal bone removal as separate procedures when both are integral to 25446
Insufficient conservative treatment documentation — payers require evidence that non-surgical management was tried and failed before approving total wrist replacement
Global period violations — billing routine post-op E/M visits within the 90-day global without modifier 24 or 25

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01What is the global period for CPT 25446?

90 days. All routine post-op care, splint changes, and dressing changes are bundled from the day of surgery through day 90. Bill unrelated E/M visits with modifier 24; use modifier 57 for a decision-for-surgery visit on the day before or day of surgery.

02Can I bill 25446 for both wrists in the same operative session?

Yes, but bilateral total wrist arthroplasty in a single session is extremely rare. If performed, append modifier 50 and document independent medical necessity for each side. Expect heightened payer scrutiny and a prior authorization requirement.

03How does 25446 differ from wrist arthrodesis codes?

25446 is prosthetic replacement — the joint is reconstructed with implants to preserve motion. Wrist fusion codes (e.g., 25800, 25810, 25825) eliminate motion entirely. Choosing the wrong code family based on the operative note is an auditable error; document why arthroplasty was selected over fusion.

04Is an assistant surgeon billable with 25446?

CMS allows assistant-at-surgery for musculoskeletal joint replacement procedures when medical necessity is documented. Bill the assistant with modifier 80 (or AS for a PA/NP/CRNA first assist). Confirm the specific payer's assistant surgeon policy, as commercial payers vary.

05What ICD-10 codes most commonly support medical necessity for 25446?

M05-series (rheumatoid arthritis with wrist involvement), M19.031/M19.032 (primary osteoarthritis, wrist), and M12.531/M12.532 (traumatic arthropathy, wrist) are the primary supporting diagnoses. The diagnosis must match the documented clinical picture — mismatch is the top denial reason for this code.

06Can 25446 be billed with intraoperative imaging codes on the same claim?

Intraoperative fluoroscopy guidance used for implant positioning is generally considered part of the surgical package and should not be separately reported. Check NCCI edits for the specific imaging code in question before billing.

Sources & references

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

Mira AI Scribe

Mira's AI scribe captures the prosthetic system name, model, and lot number from dictation, the extent of carpal resection (partial or complete), the named surgical approach, and the surgeon's stated rationale for arthroplasty over arthrodesis. That detail prevents the two most common denial triggers for 25446: missing implant documentation and inadequate medical necessity justification.

See how Mira captures CPT 25446 documentation