2025 CPT code 49215
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Tumor Excision Excision and Destruction Procedures on the Abdomen, Peritoneum, and Omentum Feed
Excision of a presacral or sacrococcygeal tumor.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., modifier 22 for increased procedural services, modifier 59 for distinct procedural service).Use of modifiers must be justified with thorough documentation.
Medical necessity is established by the presence of a presacral or sacrococcygeal tumor requiring surgical intervention for diagnosis or treatment.Documentation must support the need for the procedure based on the patient's clinical presentation and the impact of the tumor on their health.
The surgeon is responsible for the preoperative preparation, surgical excision of the tumor, hemostasis, wound irrigation and closure, as well as postoperative care and monitoring.
- Excision and Destruction Procedures on the Abdomen, Peritoneum, and Omentum
- Excision and Destruction Procedures on the Abdomen, Peritoneum, and Omentum
In simple words: This surgery removes a growth (tumor) near the base of the spine.The doctor makes a cut in the abdomen or back, removes the tumor carefully, stops any bleeding, and closes the cut.
Surgical removal of a tumor located in the presacral or sacrococcygeal region.This procedure involves careful dissection to ensure complete removal of the tumor while preserving surrounding structures such as the rectum and other key anatomical features. The approach may involve a laparotomy incision (abdominal incision) or a posterior incision, potentially including removal of the coccyx, depending on the tumor's location and size. The procedure includes irrigation, hemostasis (control of bleeding), and closure of the incision.
Example 1: A newborn presents with a sacrococcygeal teratoma.Surgical excision (49215) is performed via a posterior approach, necessitating coccygectomy., A child presents with a presacral tumor.Laparotomy is performed, with complete excision of the tumor.49215 is reported., An adult presents with a presacral tumor that requires a complex surgical excision due to its size and proximity to vital structures.Modifier 22 may be applied with appropriate documentation.
Preoperative imaging (e.g., MRI, CT scan), operative report detailing the surgical approach, tumor size and location, extent of resection, hemostasis, and pathology report confirming diagnosis.Postoperative imaging may also be necessary.
** Removal of the coccyx, if necessary to access the tumor, is included in code 49215.Do not use modifier 63 with this code.
- Revenue Code: P1G (Major Procedure - Other)
- RVU: RVUs vary based on factors such as geographical location, facility type, and payer.Consult the appropriate fee schedule for current values.
- Global Days: The global period for this procedure is not explicitly defined in the provided sources and may vary depending on payer and local practice.Documentation should clarify any extended postoperative care.
- Payment Status: Active;status as Inpatient-Only (IPO) has changed in some jurisdictions (e.g., Indiana) to allow outpatient reimbursement.Consult payer policies for specific payment status.
- Modifier TC rule: Not applicable.This code is for the entire procedure.
- Fee Schedule: Fee schedules vary by payer and location.Historical data is unavailable within provided sources.
- Specialties:Surgical Oncology, Pediatric Surgery, General Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center