2025 CPT code 23076
(Active) Effective Date: N/A Surgery - Musculoskeletal System Feed
Excision of a deep, subfascial, or intramuscular soft tissue tumor in the shoulder area, measuring less than 5 cm.
Modifiers may be applicable to this code.For example, modifier 54 (Surgical Care Only) may be used if another physician performs the post-operative management, and modifier 76 (Repeat Procedure by Same Physician) may be used if the surgeon needs to re-excise the tumor during the global period due to positive margins.
Medical necessity for this procedure must be established.This usually includes documentation of the patient's symptoms, physical exam findings, imaging results confirming the presence and characteristics of the tumor, and failed conservative management (if applicable). The documentation should justify the need for surgical excision.
The surgeon is responsible for the complete removal of the tumor, including obtaining adequate margins of healthy tissue to minimize recurrence risk.This includes pre-operative planning, intra-operative dissection and excision, and post-operative wound management.
In simple words: This procedure involves removing a tumor located deep within the muscle tissue of your shoulder. The tumor is less than 2 inches in size.The surgeon will remove the tumor and some surrounding healthy tissue to ensure complete removal. The area will then be stitched closed.
Excision, tumor, soft tissue of shoulder area, subfascial (e.g., intramuscular); less than 5 cm. This code describes the surgical removal of a tumor located within the soft tissues of the shoulder, specifically within or below the deep fascia, including intramuscular tumors. The size of the tumor is less than 5 cm in greatest diameter, including the margin necessary for complete excision. The procedure includes simple or intermediate repair of the surgical site.
Example 1: A 45-year-old patient presents with a palpable, 3 cm intramuscular lipoma within the deltoid muscle.The mass is excised using CPT code 23076., A 25-year-old athlete complains of pain and limited range of motion in their shoulder.Imaging reveals a 4 cm subfascial fibroma.The mass is removed using CPT code 23076., A 60-year-old patient with a history of soft tissue sarcoma presents with a suspicious 2 cm nodule deep within the trapezius muscle.A wide local excision is performed (CPT code 23076), and the specimen is sent for pathology to determine if it is a recurrence.
Documentation should include the size and location of the tumor (including depth relative to the fascia), operative findings, and the status of surgical margins. Pathology report confirming the diagnosis is also required.
- Specialties:Surgical specialties such as Orthopedic Surgery, General Surgery, or Plastic Surgery may perform this procedure, depending on the specific location and nature of the tumor.
- Place of Service:This procedure can be performed in various settings, including: "Ambulatory Surgical Center", "Hospital - Inpatient", "Hospital - Outpatient"