2025 CPT code 21558
(Active) Effective Date: N/A Excision/Resection - Musculoskeletal System Surgery Feed
Radical resection of a soft tissue tumor, such as a sarcoma, in the neck or anterior thorax, measuring 5 cm or greater.
Modifiers may be applicable.Modifier 22 may be appended for increased procedural services, and modifier 59 may be used to distinguish this procedure from other procedures performed at the same surgical session.
Medical necessity must be established by documenting the diagnosis of malignancy or aggressive benign tumor behavior, pre-operative imaging studies, and clinical findings supporting the need for radical resection.
The physician is responsible for administering appropriate anesthesia, prepping and draping the surgical site, making the incision, dissecting the tumor, excising the tumor with wide margins, ensuring hemostasis, irrigating the wound, placing a drain if necessary, and closing the incision in layers.They must accurately measure the tumor and margins to select the correct code.
In simple words: This procedure involves the complete removal of a cancerous or aggressive non-cancerous soft tissue tumor in the neck or chest area.The surgery removes the tumor and a significant area of the surrounding healthy tissue to minimize the chance of the tumor returning. This code applies when the tumor and the removed margin is 5 centimeters or more across.
Radical resection involves the removal of the tumor along with a wide margin of surrounding healthy tissue. This procedure is typically performed for malignant tumors or aggressive benign tumors in the neck or anterior thorax. The code is applicable when the tumor size, including the necessary margins, is 5 cm or larger.
Example 1: A patient presents with a 6 cm sarcoma in the anterior neck. The surgeon performs a radical resection, removing the tumor and a wide margin of surrounding tissue, totaling a diameter of 7 cm. Code 21558 is reported., A patient with a recurrent desmoid tumor of the chest wall measuring 5.5 cm undergoes radical resection. The surgeon removes the tumor and a wide margin of surrounding tissue. The final excised specimen measures 6 cm in diameter. Code 21558 is reported., A patient has a 4 cm malignant soft tissue tumor in the neck. A radical resection is performed, and the surgeon removes the tumor with a 2 cm margin on all sides. The total diameter of the resected specimen is 8 cm. Code 21558 is reported.
Documentation should include the type and location of the tumor, the size of the tumor, the margins taken, the total size of the resected specimen, operative details, and pathology report.
** It's crucial to distinguish this code from code 21557, which describes the same procedure but for tumors smaller than 5 cm.
- Specialties:Surgical Oncology, General Surgery, Plastic Surgery, Otolaryngology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center