2025 CPT code 21555
(Active) Effective Date: N/A Excision - Surgical Procedures on the Musculoskeletal System Surgery Feed
Excision of a subcutaneous soft tissue tumor from the neck or anterior thorax, measuring less than 3 cm.
Modifiers may be applicable depending on the specific circumstances of the procedure. Examples include modifier 22 (Increased Procedural Services) or modifier 51 (Multiple Procedures).
Medical necessity is based on the presence of a symptomatic or suspicious subcutaneous mass in the neck or anterior chest area. The decision to excise is based on factors such as the patient's symptoms, size and location of the tumor, and suspicion of malignancy.
The physician prepares the patient and administers anesthesia. An incision is made in the skin and subcutaneous tissue, exposing the tumor. Careful dissection frees the tumor, which is removed and sent for pathological examination. The wound is irrigated, bleeding is controlled, and the incision is closed in layers.
In simple words: Removal of a lump under the skin on the neck or upper chest that is smaller than 3 cm.
Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm. This code encompasses the surgical removal of a tumor located in the subcutaneous tissue (beneath the skin but above the deeper fascia) of the neck or anterior thorax (front of the chest). The procedure involves excising the tumor along with a margin of healthy tissue, and the size of the excised tumor, including the margin, is less than 3 cm.The measurement is crucial for accurate coding.
Example 1: A patient presents with a 2 cm lipoma (a benign fatty tumor) in the subcutaneous tissue of the neck. The physician excises the mass under local anesthesia., A small, palpable mass is found in the subcutaneous tissue of the anterior chest during a routine examination. Excision reveals a benign fibroma., A patient has a 1.5 cm subcutaneous cyst on the neck. The cyst is removed, along with surrounding tissue.
Documentation must include size and location of the tumor, operative report detailing the excision procedure, including margin size, and pathology report confirming the diagnosis.
- Specialties:General Surgery, Plastic Surgery, Dermatologic Surgery
- Place of Service:Office, Ambulatory Surgical Center, Outpatient Hospital