How To Use CPT Code 25316

CPT code 25316 describes a surgical procedure known as flexor origin slide. 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 25316?

CPT 25316 is a code used to describe the surgical procedure known as flexor origin slide. This procedure involves releasing the origin of the flexor tendons in order to allow the muscles to slide distally. It is performed to improve the appearance and function of a severely deformed hand, wrist, or fingers. Additionally, a tendon transfer may be performed, where a tendon is moved from one location in the forearm or wrist to another.

2. Official Description

The official description of CPT code 25316 is: ‘Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist with tendon(s) transfer.’

3. Procedure

The flexor origin slide procedure involves several steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision on the inner aspect of the volar side of the forearm, extending up to its midpoint over the ulna.
3. The ulnar nerve is released.
4. The provider incises the tendon origin from the medial epicondyle and releases the muscles from the medial epicondyle and ulna, extending almost to the wrist.
5. The artery and nerve are released.
6. The origin of the flexor digitorum profundus from the radius to the index finger and the remaining origin of the flexor digitorum sublimis from the coronoid process are released.
7. The wrist and fingers are extended to identify any remaining tight bands, which are then released.
8. The ulnar nerve is transplanted anterior to the brachialis tendon.
9. A donor tendon is freed from its attached bone, and a tunnel is created between the two tendons in a straight line.
10. The damaged tendon is passed through the tunnel and attached to the donor tendon, securing it with sutures.
11. The tendons are divided proximal to the wrist.
12. The muscles are then slid over the periosteum and fixed in place.
13. The median and ulnar nerves are returned.
14. The area is irrigated, checked for bleeding, instruments are removed, and the incision is closed.

4. Qualifying circumstances

CPT 25316 is typically performed for patients with severe hand, wrist, or finger deformities that affect their appearance and function. It is commonly used for conditions such as cerebral palsy and Volkmann contracture. The procedure is performed by a qualified healthcare provider and may involve a tendon transfer in addition to the flexor origin slide.

5. When to use CPT code 25316

CPT code 25316 should be used when a provider performs a flexor origin slide procedure with or without a tendon transfer on the forearm and/or wrist. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT code 25316, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the flexor origin slide procedure
• Details of the procedure performed, including any tendon transfers
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures or interventions performed
• Any complications or unexpected findings
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 25316, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should be performed by a qualified healthcare provider and should include the necessary documentation to support the claim. It is also important to follow any additional billing guidelines provided by the payer or relevant coding guidelines.

8. Historical information

CPT code 25316 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 25316

There are several similar codes to CPT 25316 that may be used to describe related procedures. These include:

• CPT 25310: Flexor origin slide, forearm and/or wrist without tendon transfer
• CPT 25320: Flexor origin slide, forearm and/or wrist with tendon transfer, single
• CPT 25332: Flexor origin slide, forearm and/or wrist with tendon transfer, multiple
• CPT 25335: Flexor origin slide, forearm and/or wrist with tendon transfer, multiple; each additional tendon transfer (List separately in addition to code for primary procedure)
• CPT 25337: Flexor origin slide, forearm and/or wrist with tendon transfer, multiple; each additional tendon transfer (List separately in addition to code for primary procedure)

9. Examples

1. A patient with cerebral palsy undergoes a flexor origin slide procedure with a tendon transfer to improve hand function and appearance.
2. A patient with Volkmann contracture undergoes a flexor origin slide procedure without a tendon transfer to improve finger mobility.
3. A patient with a severe hand deformity undergoes a flexor origin slide procedure with multiple tendon transfers to correct finger positioning.
4. A patient with a wrist deformity undergoes a flexor origin slide procedure with a single tendon transfer to improve wrist function.
5. A patient with a finger deformity undergoes a flexor origin slide procedure with multiple tendon transfers to correct finger alignment.
6. A patient with a combination of hand, wrist, and finger deformities undergoes a flexor origin slide procedure with multiple tendon transfers to improve overall hand function and appearance.
7. A patient with a congenital hand deformity undergoes a flexor origin slide procedure without a tendon transfer to improve hand mobility.
8. A patient with a traumatic hand injury undergoes a flexor origin slide procedure with a tendon transfer to restore finger function.