2025 CPT code 27634
(Active) Effective Date: N/A Revision Date: N/A Surgery - Excision Procedures on the Leg (Tibia and Fibula) and Ankle Joint Musculoskeletal System Feed
Excision of a subfascial soft tissue tumor in the leg or ankle area measuring 5 cm or greater.
Modifiers may be applicable depending on the circumstances of the service (e.g., modifier 51 for multiple procedures, modifier 76 for a repeat procedure, modifier 80 for assistant surgeon). Consult current CPT guidelines for specific modifier application rules.
Medical necessity is established by the presence of a symptomatic or potentially cancerous soft tissue tumor requiring excision for diagnostic or therapeutic purposes. The size and location of the tumor may influence the extent of the surgical intervention and the necessity for the procedure.
The surgeon performs the excision, controlling bleeding and closing the incision in layers.Preoperative and postoperative care are typically billed separately.
- Musculoskeletal System
- Musculoskeletal System > Excision Procedures on the Leg (Tibia and Fibula) and Ankle Joint
In simple words: The doctor removes a tumor from deep within the leg or ankle tissues.The tumor is 5 centimeters or larger.Additional procedures, like fixing blood vessels or extensive stitching, are billed separately.
This CPT code describes the surgical excision of a benign or malignant subfascial soft tissue tumor located in the leg or ankle region.The tumor's greatest diameter, including the necessary margin for complete removal, measures 5 centimeters or more. The procedure involves removal of the tumor along with narrow margins of surrounding normal tissue.Dissection or elevation of tissue planes to facilitate resection is included, but significant vessel exploration, neuroplasty, extensive undermining, or complex repair are reported separately.This code does not include excision of cutaneous lesions.
Example 1: A 55-year-old male presents with a palpable mass in his right calf, measuring 6 cm in diameter.An ultrasound confirms a subfascial soft tissue tumor. The surgeon performs an excision, removing the mass along with a narrow margin of surrounding tissue. The incision is closed in layers., A 28-year-old female has a 5.5 cm intramuscular tumor in her left ankle. The surgeon excises the tumor and performs a primary closure. The patient is then scheduled for physical therapy., A 72-year-old patient presents with a large (7cm) subfascial mass on the anterior aspect of her right tibia.A biopsy confirms a benign soft tissue tumor. The mass is excised.Due to the size and location, the surgeon uses local flap reconstruction to close the defect, which is coded separately.
Preoperative imaging (e.g., ultrasound, MRI), operative report detailing tumor size, location, and margins of excision, pathology report confirming the diagnosis, and postoperative care notes.
** Accurate code selection requires careful documentation of the tumor's size and location to ensure appropriate reimbursement.Always consult current CPT guidelines and payer-specific policies.
- Payment Status: Active
- Modifier TC rule: The TC modifier is generally not applicable to this code, as it refers to the technical component of a procedure, which is typically encompassed by the surgical excision.
- Specialties:Orthopedic Surgery, General Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)