How To Use CPT Code 21011

CPT code 21011 describes the excision of a soft tissue tumor from the face or scalp that is subcutaneous and less than 2 cm in size. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21011?

CPT 21011 is used to describe the excision of a subcutaneous soft tissue tumor from the face or scalp that is less than 2 cm in size. This procedure involves the removal of a small tumor directly under the skin using a surgical approach.

2. Official Description

The official description of CPT code 21011 is: ‘Excision, tumor, soft tissue of face or scalp, subcutaneous less than 2 cm.’

3. Procedure

During the excision of a soft tissue tumor with CPT 21011, the physician performs the following steps:

1. The patient is brought to the operating room and given appropriate anesthesia.
2. The operative site (face or scalp) is prepped and draped.
3. A linear incision is made around the tumor site.
4. The incision is extended around the tumor to provide adequate access.
5. A sharp scalpel is used to carefully dissect the subcutaneous tumor from the surrounding tissue margin.
6. The tumor is removed using surgical forceps.
7. Once the tumor is satisfactorily removed, the incision is closed in a layered fashion.

4. Qualifying circumstances

CPT 21011 is appropriate for patients who require the excision of a subcutaneous soft tissue tumor from the face or scalp that is less than 2 cm in size. The procedure is typically performed by a physician in an operating room setting. It is important to note that CPT code 21011 is specifically for subcutaneous tumors and should not be used for tumors that are 2 cm or larger.

5. When to use CPT code 21011

CPT code 21011 should be used when a physician performs the excision of a subcutaneous soft tissue tumor from the face or scalp that is less than 2 cm in size. If the tumor is 2 cm or larger, a different CPT code should be used. It is important to accurately measure the size of the tumor to determine the appropriate code to report.

6. Documentation requirements

To support a claim for CPT code 21011, the physician must document the following information:

• Patient’s diagnosis and the need for tumor excision
• Size of the tumor (less than 2 cm)
• Date of the procedure
• Details of the surgical approach and technique used
• Description of the tumor excision process
• Any complications or additional procedures performed
• Signature of the performing physician

7. Billing guidelines

When billing for CPT code 21011, ensure that the excision is performed on a subcutaneous soft tissue tumor that is less than 2 cm in size. It is important to accurately measure the size of the tumor to determine the appropriate code to report. CPT code 21011 should not be reported for tumors that are 2 cm or larger. Additionally, it is important to follow any specific billing guidelines provided by the payer to ensure accurate reimbursement.

8. Historical information

CPT code 21011 was added to the Current Procedural Terminology system on January 1, 2010. There have been no updates to the code since its addition.

9. Examples

1. A physician performs the excision of a 1.5 cm subcutaneous soft tissue tumor from a patient’s face.
2. A surgeon removes a 1 cm subcutaneous soft tissue tumor from a patient’s scalp.
3. A dermatologist excises a 1.8 cm subcutaneous soft tissue tumor from a patient’s face.
4. A plastic surgeon performs the excision of a 1.2 cm subcutaneous soft tissue tumor from a patient’s scalp.
5. An oncologist removes a 1.7 cm subcutaneous soft tissue tumor from a patient’s face.
6. A maxillofacial surgeon excises a 1.3 cm subcutaneous soft tissue tumor from a patient’s scalp.
7. A general surgeon performs the excision of a 1.6 cm subcutaneous soft tissue tumor from a patient’s face.
8. A plastic surgeon removes a 1.4 cm subcutaneous soft tissue tumor from a patient’s scalp.
9. An otolaryngologist excises a 1.9 cm subcutaneous soft tissue tumor from a patient’s face.
10. A dermatologist performs the excision of a 1.1 cm subcutaneous soft tissue tumor from a patient’s scalp.