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2025 CPT code 23073

Excision of a subfascial (intramuscular) soft tissue tumor in the shoulder area, 5 cm or greater.

Refer to the CPT manual for complete coding guidelines and instructions.

Modifiers may be applicable depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 76 for a repeat procedure, 59 for a distinct procedural service). Refer to the CPT guidelines for appropriate modifier usage.

Medical necessity is established by the presence of a symptomatic or concerning mass requiring surgical excision to rule out malignancy or to alleviate symptoms.The size and location of the tumor, as well as the patient's clinical presentation, will influence the determination of medical necessity.

The surgeon's responsibility includes prepping the patient, making the incision, excising the tumor with a margin of surrounding tissue, irrigating the wound, closing the incision, and submitting the specimen for pathology.

IMPORTANT:Related codes include 23076 (for subfascial tumors less than 5cm), 23071 and 23075 (for subcutaneous tumors of different sizes), and 23077 and 23078 (for radical resections of malignant neoplasms).

In simple words: The doctor removes a lump (tumor) from a muscle in the shoulder area. This code is used when the lump is 5 centimeters (about 2 inches) or larger.

This CPT code (23073) describes the surgical excision of a soft tissue tumor located subfascially (e.g., intramuscularly) within the shoulder area. The procedure involves the removal of the tumor and a margin of surrounding healthy tissue.The code is specifically for tumors with a greatest diameter of 5 centimeters or greater.Dissection or elevation of tissue planes to facilitate tumor resection is included.However, significant vessel exploration, neuroplasty, extensive undermining, or complex repairs to close defects are reported separately.The excised tissue is sent for pathological examination.

Example 1: A 55-year-old male presents with a palpable mass in his right deltoid muscle, measuring 6 cm in diameter.The mass is excised, and the pathology report confirms a benign lipoma., A 70-year-old female with a history of breast cancer presents with a 7-cm mass in her left infraspinatus muscle.A radical resection is performed, and the pathology reveals a metastatic lesion., A 30-year-old male presents with a 5-cm mass in the rotator cuff region of his shoulder, which is determined to be a fibroma via imaging and clinical examination.The mass is excised, and the patient’s surgical wound is closed. Pathology results indicate a benign neoplasm.

** The size of the tumor is a critical factor for code selection.Accurate documentation of tumor size is essential for appropriate reimbursement.

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