How To Use CPT Code 28225

CPT 28225 describes a surgical procedure known as tenolysis, specifically for the extensor tendon in the foot. This article will provide an overview of the code, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of when CPT 28225 may be used.

1. What is CPT Code 28225?

CPT 28225 is a code used to describe the surgical procedure of tenolysis, specifically for the extensor tendon in the foot. This procedure involves the removal of adhesions that affect a single extensor tendon, allowing for improved movement and reduced pain caused by tendonitis.

2. Official Description

The official description of CPT code 28225 is: ‘Tenolysis, extensor, foot; single tendon.’

3. Procedure

1. During the procedure, the provider begins by making an incision on the dorsal (top) aspect of the foot.
2. They carefully dissect the soft tissue, being cautious not to damage any underlying blood vessels or nerves.
3. The provider then identifies the extensor tendon and proceeds to remove the adhesions surrounding it using a blunt scalpel and forceps.
4. Finally, they close the soft tissue with sutures.

4. Qualifying circumstances

CPT 28225 is typically performed on patients who have adhesions affecting a single extensor tendon in the foot, resulting in pain and limited movement. These adhesions may be caused by inflammation or injury during surgery, leading to the formation of fibrous bands between tissues and organs. The procedure is aimed at improving the patient’s condition by freeing up the adhesions and allowing for better tendon function.

5. When to use CPT code 28225

CPT code 28225 should be used when a provider performs tenolysis on a single extensor tendon in the foot. It is important to note that this code is specific to a single tendon and should not be used for procedures involving two or more tendons. In such cases, CPT code 28226 should be utilized.

6. Documentation requirements

When reporting CPT code 28225, the provider must ensure that the following documentation is included:

• The patient’s diagnosis and the need for tenolysis
• Details of the procedure, including the specific extensor tendon involved
• Date of the procedure
• Start and end time of the procedure
• Any additional relevant information, such as the use of sutures or other techniques
• Provider’s signature

7. Billing guidelines

When billing for CPT code 28225, it is important to ensure that the procedure performed aligns with the official description. Additionally, providers should be aware of any specific guidelines or modifiers that may be required for accurate billing. It is also crucial to review any bundling or unbundling rules that may apply to this code.

8. Historical information

CPT code 28225 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. Examples

1. A patient undergoes tenolysis of the extensor tendon in their foot to alleviate pain and improve movement.
2. A provider performs tenolysis on a patient’s foot to address adhesions affecting a single extensor tendon.
3. Tenolysis is performed on a patient’s foot to release adhesions and improve the function of a single extensor tendon.
4. A provider surgically removes adhesions surrounding a single extensor tendon in a patient’s foot, allowing for better movement and reduced pain.
5. Tenolysis is performed on a patient’s foot to free up a single extensor tendon from adhesions, improving their overall condition.
6. A provider performs tenolysis on a patient’s foot to address adhesions affecting a specific extensor tendon, resulting in improved function and reduced pain.
7. Tenolysis is performed on a patient’s foot to release adhesions and restore proper movement to a single extensor tendon.
8. A provider surgically removes adhesions affecting a single extensor tendon in a patient’s foot, resulting in improved mobility and reduced discomfort.
9. Tenolysis is performed on a patient’s foot to alleviate pain and restore normal function to a single extensor tendon.
10. A provider performs tenolysis on a patient’s foot to address adhesions affecting a specific extensor tendon, leading to improved range of motion and decreased pain.