How To Use CPT Code 21725

CPT 21725 describes the division of the sternocleidomastoid muscle in the neck to treat torticollis, a condition characterized by a stiff neck and muscle spasms that cause the head to tilt to one side. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21725?

CPT 21725 is a code used to describe a surgical procedure in which the sternocleidomastoid muscle in the neck is divided to treat torticollis. Torticollis is a condition that causes a stiff neck and muscle spasms, resulting in the head tilting to one side. The procedure involves making an incision above the medial end of the clavicle (collar bone), exposing the sternocleidomastoid muscle, and cutting the ends of the tendon to eliminate any remaining contracted muscle. A cast is then applied to limit movement during the healing process.

2. Official Description

The official description of CPT code 21725 is: ‘Division of sternocleidomastoid for torticollis, open operation with cast application.’

3. Procedure

The procedure for CPT 21725 involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. An incision is made above the medial end of the clavicle to expose the sternocleidomastoid muscle.
3. An incision is made into the tendon sheath, and the tendon is drawn outside of the wound.
4. The ends of the tendon are cut to eliminate any remaining contracted muscle.
5. The provider confirms the restoration of the patient’s neck movement.
6. The area is irrigated, checked for bleeding, and any instruments are removed.
7. The incision is closed, and a cast is applied to limit patient movement during the healing process.

4. Qualifying circumstances

CPT 21725 is performed for patients with torticollis, a condition characterized by a stiff neck and muscle spasms that cause the head to tilt to one side. The procedure is typically performed by a qualified healthcare professional and requires the patient to meet specific diagnostic criteria for torticollis. The patient must have tried conservative treatments without success, and the division of the sternocleidomastoid muscle is deemed necessary to alleviate symptoms and improve neck movement.

5. When to use CPT code 21725

CPT code 21725 should be used when a qualified healthcare professional performs the division of the sternocleidomastoid muscle to treat torticollis. It is important to ensure that the patient meets the necessary diagnostic criteria and has exhausted conservative treatment options before considering this surgical intervention. The code should only be used when the procedure is performed with the application of a cast to limit patient movement during the healing process.

6. Documentation requirements

To support a claim for CPT 21725, the healthcare professional must document the following information:

• Patient’s diagnosis of torticollis and the need for surgical intervention
• Details of the procedure, including the incision site, exposure of the sternocleidomastoid muscle, and division of the tendon
• Confirmation of the restoration of the patient’s neck movement
• Documentation of any complications or unexpected findings during the procedure
• Application of a cast to limit patient movement during the healing process
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 21725, it is important to ensure that the procedure meets the necessary criteria for torticollis and that the division of the sternocleidomastoid muscle is performed with the application of a cast. The code should not be reported with other codes unless there are additional procedures or services performed during the same encounter that are separately billable. It is essential to follow the specific guidelines provided by the payer and to include all required documentation to support the claim.

8. Historical information

CPT 21725 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 21725

While there are no similar codes to CPT 21725, there are other codes within the range of repair, revision, and/or reconstruction procedures on the neck (soft tissues) and thorax (21685-21750) that may be applicable for different procedures or conditions involving the neck and thoracic region.

9. Examples

1. A patient with torticollis undergoes the division of the sternocleidomastoid muscle, and a cast is applied to limit movement during the healing process.
2. A healthcare professional performs the surgical procedure on a pediatric patient with severe torticollis, followed by the application of a cast.
3. A patient with chronic torticollis undergoes the division of the sternocleidomastoid muscle, and a cast is applied to support the healing process.
4. A healthcare professional performs the procedure on an adult patient with recurrent torticollis, followed by the application of a cast for stabilization.
5. A patient with congenital torticollis undergoes the surgical intervention, and a cast is applied to maintain the corrected position of the neck.
6. A healthcare professional performs the procedure on a patient with acquired torticollis due to trauma, followed by the application of a cast for immobilization.
7. A patient with idiopathic torticollis undergoes the division of the sternocleidomastoid muscle, and a cast is applied to support the healing process.
8. A healthcare professional performs the surgical procedure on a patient with spasmodic torticollis, followed by the application of a cast for stabilization.
9. A patient with secondary torticollis due to cervical spine pathology undergoes the division of the sternocleidomastoid muscle, and a cast is applied to limit movement during the healing process.
10. A healthcare professional performs the procedure on a patient with torticollis associated with a musculoskeletal disorder, followed by the application of a cast for immobilization and support.