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2025 CPT code 21557

Radical resection of a tumor (e.g., sarcoma) in the neck or anterior thorax; less than 5 cm.

Follow current CPT coding guidelines and payer-specific instructions when coding this procedure.Precise documentation is critical for accurate coding and reimbursement.

Modifiers may be applicable depending on the specific circumstances of the case. Consult the CPT manual for appropriate modifier usage.

Medical necessity for a radical resection is typically established when a malignant or aggressive benign soft tissue tumor is present.The extent of the resection is driven by the need to achieve clear surgical margins to prevent recurrence and improve prognosis.

The surgeon's responsibilities include preoperative assessment, surgical planning, performing the radical resection, ensuring adequate margins are taken, hemostasis, wound closure, and postoperative care.Pathology consultation is typically involved.

IMPORTANT Code 21558 is used for tumors 5 cm or greater in size. For radical resection of tumors of cutaneous origin (e.g., melanoma), refer to codes 11600-11646.

In simple words: The doctor removes a cancerous tumor from the neck or chest area, taking out a significant amount of healthy tissue around it to ensure all the cancer is gone. The tumor and the surrounding area removed are less than 5 centimeters across.

This CPT code describes the surgical procedure of radical resection of a tumor, such as a sarcoma, located in the soft tissues of the neck or anterior thorax.The procedure involves the extensive removal of the tumor along with a wide margin of surrounding normal tissue. The greatest diameter of the tumor plus the margins required for complete excision measures less than 5 cm.Appreciable vessel exploration, neuroplasty, or complex repair are reported separately.This is typically performed for malignant or aggressive benign tumors.

Example 1: A 45-year-old male presents with a palpable mass in the right anterior neck. Imaging reveals a 4 cm sarcoma. The surgeon performs a radical resection of the tumor, removing a wide margin of surrounding tissue., A 60-year-old female is diagnosed with a 3 cm sarcoma in the left supraclavicular region. The surgeon performs a radical neck dissection including resection of the tumor and surrounding tissues., A 30-year-old male presents with a rapidly growing mass in the anterior chest wall suspected to be a sarcoma. A radical resection of the tumor is performed, measuring 4.5 cm with margins.

* Thorough history and physical examination.* Imaging studies (e.g., ultrasound, CT scan, MRI) demonstrating tumor location and size.* Pathology report confirming diagnosis and margins.* Operative report detailing the surgical technique and margins resected.* Postoperative progress notes.

** Accurate assessment of tumor size and margins is crucial for appropriate code selection.Consult with surgical oncology or related specialists if any uncertainties exist regarding code selection.

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