2025 CPT code 23078
(Active) Effective Date: N/A Revision Date: N/A Surgery - Excision/Resection Soft Tissue Tumors Musculoskeletal System Feed
Radical resection of a soft tissue tumor (e.g., sarcoma) in the shoulder area; 5 cm or greater.
Modifiers may be applicable to reflect specific circumstances such as multiple procedures (51), bilateral procedures (50), or additional procedures performed in the same surgical session (59).
Medical necessity for radical resection of a soft tissue sarcoma is established by the presence of a malignant tumor requiring aggressive surgical intervention to achieve complete resection and to prevent local recurrence or metastasis. Size of the tumor and involvement of surrounding structures also plays a critical role in justifying this extensive approach.
The clinical responsibility involves surgical excision of the tumor and surrounding tissue. This includes meticulous dissection to preserve neurovascular structures, appropriate closure of the surgical site and potentially additional procedures depending on the complexity of the case.
In simple words: The doctor removes a cancerous soft tissue tumor (like a sarcoma) from the shoulder area.This involves taking out a larger area around the tumor to make sure all cancer cells are gone. The total size of the area removed is 5 centimeters or more.
This CPT code encompasses the radical resection of a soft tissue malignant tumor, such as a sarcoma, located in the shoulder region.The procedure involves the extensive excision of the tumor, exceeding its dimensions to include surrounding tissues and anatomical structures suspected of involvement.The combined measurement of the tumor's greatest diameter and the necessary margins for complete excision must be 5 centimeters or more. The procedure includes dissection or elevation of tissue planes to facilitate tumor resection.Appreciable vessel exploration and/or neuroplasty, extensive undermining, or complex repair techniques to close the defect should be reported separately using appropriate codes.
Example 1: A 55-year-old male presents with a large, palpable mass in his right shoulder. Imaging studies confirm a high-grade sarcoma measuring 6cm in diameter. Radical resection is performed, removing the tumor along with a wide margin of surrounding tissue.Pathology confirms complete excision of the malignancy., A 30-year-old female is diagnosed with a 7cm sarcoma in her left shoulder area.Due to the size and location, radical resection is performed.The surgeon dissects significant muscle tissue to ensure complete tumor removal.Post-operative recovery is uneventful., A 60-year-old patient has a recurrent sarcoma in the shoulder. Previous surgery was incomplete.A second radical resection is performed, this time with wider margins and possibly requiring reconstruction with tissue flaps or grafts, which would be billed separately.
* Preoperative imaging (e.g., MRI, CT scan) demonstrating tumor size and location.* Operative report detailing the extent of resection, tissue margins, and any complications.* Pathology report confirming the diagnosis and adequacy of resection margins.* Postoperative imaging (if applicable) to assess for recurrence or residual tumor.* Patient's medical history, including prior treatment for the condition.
** This code is used for malignant tumors; for benign tumors, other codes apply.Always ensure proper documentation supports the medical necessity and technical aspects of the procedure.Refer to official CPT coding guidelines for the most current information.
- Revenue Code: P3D (MAJOR PROCEDURE, ORTHOPEDIC - OTHER)
- Payment Status: Active
- Modifier TC rule: Technical Component (TC) modifier may be applicable depending on the specific services performed and payer requirements. This is typically determined by the surgical setting.
- Specialties:Orthopedic Surgery, Surgical Oncology
- Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Outpatient Hospital