2025 CPT code 25040
Effective Date: N/A Surgery - Surgical Procedures on the Musculoskeletal System Feed
Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign body.
Modifiers may be applicable depending on specific circumstances, such as bilateral procedures, staged procedures, or unusual complexity. Consult modifier guidelines for appropriate usage.
Medical necessity for this procedure must be established through documentation of the patient's symptoms, diagnostic findings (e.g., imaging, physical examination), and the clinical rationale for performing the arthrotomy. The documentation should clearly demonstrate that the procedure is necessary for diagnostic or therapeutic purposes.
The physician performs the surgical procedure, including incision, exploration, drainage, removal of foreign bodies, irrigation, and closure. They are responsible for pre- and post-operative care.
In simple words: The doctor will make a small cut in your wrist to look inside the joint, drain any fluid buildup, or take out something that shouldn't be there. They'll clean the area and stitch it closed.
This procedure involves incising the wrist joint for exploration, drainage of any fluid or abscess, or removal of a foreign body. After prepping and anesthetizing the patient, the provider makes an incision over the wrist or midpalm, dissecting down to the joint capsule. The capsule is then opened to access the joint. The provider explores the joint space, removes any foreign bodies (if present), and drains fluid or abscesses (if necessary). The wound is irrigated, sutured, and a drain may be placed.
Example 1: A patient presents with a painful wrist after a fall, with suspected bone fragments in the joint. The physician performs an arthrotomy of the radiocarpal joint to explore the joint and remove the fragments., A patient has persistent wrist pain and swelling, and imaging suggests an abscess within the midcarpal joint. The physician performs an arthrotomy to drain the abscess., A patient experiences wrist pain and limited range of motion after a penetrating injury. An arthrotomy is performed to explore the radiocarpal joint, remove any foreign material, and assess for damage to ligaments and tendons.
Documentation should include details of the procedure, including the specific joint accessed (radiocarpal or midcarpal), findings during exploration, any foreign bodies or fluid drained, and the method of closure. Any associated injuries or complications should also be documented. Operative reports, imaging studies, and pre- and post-operative evaluations should be maintained.
** This code includes the application and removal of the first cast, splint, or traction device, if performed. Supplies may be reported separately. Subsequent replacement of these devices may be reported separately. This procedure does not include extensive undermining or complex repair, which should be reported separately if performed.
- Specialties:Orthopedic Surgery, Hand Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Inpatient Hospital