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2025 CPT code 21556

Excision of a subfascial (e.g., intramuscular) soft tissue tumor in the neck or anterior thorax, less than 5 cm.

Follow the official CPT guidelines regarding excision of soft tissue tumors and the proper documentation requirements for accurate coding and reimbursement.

Modifiers may be applicable depending on the circumstances of the procedure. For example, modifier 51 (multiple procedures) may be used if multiple procedures are performed on the same day. Modifier 76 (repeat procedure by the same physician) may be used if the procedure is repeated by the same physician.

Surgical excision is medically necessary when a patient presents with a symptomatic mass in the neck or anterior thorax that is potentially malignant or significantly compromises the surrounding tissue.The diagnosis should be based on clinical examination and appropriate imaging.

The surgeon's responsibilities include preoperative planning, appropriate patient preparation and anesthesia administration, surgical excision of the tumor with meticulous dissection to preserve vital structures, hemostasis (control of bleeding), wound irrigation, placement of drains if needed, and layered wound closure.Postoperative care instructions and follow-up are also part of the clinical responsibility.

IMPORTANT Similar codes include 21555 (subcutaneous tumor excision, <3cm) and other codes for excision of tumors in other locations.For malignant tumors or those requiring radical resection, code 21557 may be more appropriate.If the tumor is located in a different area, refer to the appropriate CPT codes for that region.

In simple words: The doctor removes a growth (tumor) from the muscle tissue of the neck or upper chest.The growth is less than 5 centimeters across. The doctor removes the growth with a small amount of surrounding tissue.

This CPT code, 21556, represents the surgical excision of a benign or malignant soft tissue tumor located in the subfascial (e.g., intramuscular) region of the neck or anterior thorax.The tumor's greatest diameter, including the margins necessary for complete excision, must be less than 5 centimeters. The procedure encompasses dissection and elevation of tissue planes to facilitate tumor resection, but does not include significant removal of surrounding normal tissue.Appreciable vessel exploration/neuroplasty and complex repairs are separately reported.

Example 1: A 45-year-old male presents with a palpable 4 cm mass in his right sternocleidomastoid muscle.The mass is excised completely, pathology reveals a benign fibroma., A 60-year-old female presents with a rapidly growing 3 cm mass in her pectoral muscle. A biopsy confirms a malignant sarcoma. Surgical excision, code 21556, is performed, followed by adjuvant therapies., A 20-year-old male sustains a penetrating injury to the neck during a motor vehicle accident, resulting in a subfascial hematoma that requires surgical debridement and evacuation.The surgeon excises necrotic tissue and addresses associated soft tissue injury.

** Always verify code appropriateness based on the individual patient's clinical circumstances and payer guidelines. The size of the tumor should be measured at the time of excision and should include margins of excision.

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