2025 CPT code 21554
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Excision Procedures on the Neck (Soft Tissues) and Thorax Musculoskeletal System Feed
Excision of a subfascial soft tissue tumor in the neck or anterior thorax, 5 cm or greater.
Modifiers may be applicable depending on the circumstances of the surgery.For instance, modifier 51 (multiple procedures) or 76 (repeat procedure) may be necessary.
Medical necessity is established by the presence of a symptomatic or enlarging mass requiring surgical intervention for diagnosis and treatment. The size and location of the tumor may justify the surgical approach coded.
The surgeon is responsible for the entire procedure, including incision, tumor dissection, hemostasis (control of bleeding), nerve protection, wound irrigation, drainage placement (if necessary), and layered wound closure.Anesthesia services may be provided by the surgeon or another qualified healthcare professional, requiring separate billing.
In simple words: This code describes the removal of a deep tumor in the neck or upper chest area that is 5 centimeters or larger. The surgeon makes an incision, carefully removes the tumor, and closes the wound.This is a more extensive procedure than removing smaller tumors.
This CPT code encompasses the surgical excision of a subfascial soft tissue tumor located in the neck or anterior thorax region, measuring 5 centimeters or larger in its greatest dimension.The procedure involves meticulous dissection to remove the tumor while preserving adjacent vital structures, including nerves and blood vessels.The surgical approach may necessitate ligation and transection of feeding vessels, and the wound is typically irrigated and closed in layers, often with the placement of a drain.
Example 1: A 55-year-old male patient presents with a palpable mass in the right anterior neck, measuring 6 cm in diameter.A biopsy confirms a benign subfascial soft tissue tumor.Surgical excision is performed using CPT code 21554., A 38-year-old female patient has a 7 cm subfascial tumor in the left neck.Due to the size and location, the surgeon uses CPT code 21554 for its removal.Significant bleeding occurs, necessitating the use of an additional code for vessel exploration and repair., A 62-year-old male presents with a 5 cm subfascial mass in the anterior thorax. A radical excision is deemed necessary due to the aggressive nature of the tumor, requiring the use of CPT 21554. Significant surrounding tissue is removed.
Preoperative imaging (e.g., ultrasound, MRI), operative report detailing the approach, tumor size and location, steps taken to preserve vital structures,pathology report confirming the diagnosis and tumor size, and postoperative progress notes are required.
** Accurate measurement of the tumor is crucial for appropriate code selection.If the tumor extends beyond the subfascial plane or involves bone, different CPT codes may apply.Always consult the most up-to-date CPT manual and payer guidelines for complete and accurate coding.
- Revenue Code: P5B (Ambulatory Procedures - Musculoskeletal)
- RVU: This information varies depending on location and payer. Consult the appropriate fee schedule.
- Global Days : The global period for this procedure is not explicitly defined in the CPT code description.Refer to payer-specific guidelines for clarification.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule : Historical fee schedule data is not included in the provided information. Consult payer-specific fee schedules for historical reimbursement rates.
- Specialties:Surgical Oncology, General Surgery, Otolaryngology
- Place of Service:Office, Ambulatory Surgical Center, Inpatient Hospital