How To Use CPT Code 21013

CPT code 21013 describes the excision of a soft tissue tumor on the face or scalp that is subfascial (e.g., subgaleal, intramuscular) 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 21013?

CPT 21013 is used to describe the excision of a soft tissue tumor on the face or scalp that is subfascial and less than 2 cm in size. This code is specifically for tumors that are located below the fascia, such as subgaleal or intramuscular tumors. The excision procedure involves removing the tumor from the surrounding tissue and closing the incision with sutures.

2. Official Description

The official description of CPT code 21013 is: ‘Excision, tumor, soft tissue of face and scalp, subfascial (e.g., subgaleal, intramuscular) less than 2 cm.’

3. Procedure

During the excision procedure for CPT 21013, the provider first preps and anesthetizes the patient. They then make a linear incision at the tumor site on the face or scalp. The incision is extended into the deep fascial layer to locate the tumor. Once the tumor is well localized, the provider uses a sharp scalpel to dissect the tumor from the surrounding tissue margin. The tumor is then removed using surgical forceps. Finally, the provider closes the incision with sutures in a layered fashion.

4. Qualifying circumstances

CPT 21013 is used for the excision of subfascial soft tissue tumors on the face or scalp that are less than 2 cm in size. These tumors are typically benign, but the excision is performed to rule out any cancerous condition. The procedure is performed by a qualified healthcare professional and requires appropriate prepping and anesthesia.

5. When to use CPT code 21013

CPT code 21013 should be used when a subfascial soft tissue tumor on the face or scalp needs to be excised and meets the criteria of being less than 2 cm in size. It is important to accurately document the size of the tumor and ensure that it is subfascial in nature. If the tumor is larger than 2 cm, CPT code 21014 should be used instead.

6. Documentation requirements

To support a claim for CPT 21013, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for tumor excision
• Size and location of the tumor
• Details of the excision procedure, including the incision, dissection, and removal of the tumor
• Method of closure, such as sutures
• Any additional procedures performed during the same session
• Signature of the healthcare professional performing the excision

7. Billing guidelines

When billing for CPT 21013, ensure that the excision procedure meets the criteria of being subfascial and less than 2 cm in size. It is important to accurately document the size and location of the tumor to support the claim. CPT code 21013 should not be reported if the tumor is larger than 2 cm, in which case CPT code 21014 should be used. It is also important to follow any specific billing guidelines provided by the payer or coding guidelines.

8. Historical information

CPT code 21013 was added to the Current Procedural Terminology system on January 1, 2010. There have been no updates to the code since its addition.

9. Similar codes to CPT 21013

There are several similar codes to CPT 21013 that are used for excision procedures on the head. These include:

• CPT 21014: Excision, tumor, soft tissue of face and scalp, subfascial (e.g., subgaleal, intramuscular), 2 cm or greater
• CPT 21011: Excision, tumor, soft tissue of face and scalp, subcutaneous; less than 2 cm
• CPT 21012: Excision, tumor, soft tissue of face and scalp, subcutaneous; 2 cm or greater
• CPT 21015: Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm
• CPT 21016: Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater

9. Examples

1. A provider excises a subfascial soft tissue tumor measuring 1.5 cm on the scalp of a patient.
2. A surgeon performs the excision of a subgaleal tumor measuring 1 cm on the face of a patient.
3. A dermatologist removes an intramuscular soft tissue tumor measuring 1.8 cm on the face of a patient.
4. A plastic surgeon excises a subfascial tumor measuring 1.2 cm on the scalp of a patient.
5. An otolaryngologist performs the excision of an intramuscular tumor measuring 1.5 cm on the face of a patient.
6. A maxillofacial surgeon removes a subgaleal soft tissue tumor measuring 1.7 cm on the scalp of a patient.
7. A provider excises a subfascial tumor measuring 1.3 cm on the face of a patient.
8. A dermatologist performs the excision of an intramuscular soft tissue tumor measuring 1.6 cm on the scalp of a patient.
9. A plastic surgeon removes a subgaleal tumor measuring 1.4 cm on the face of a patient.
10. An otolaryngologist excises a subfascial soft tissue tumor measuring 1.9 cm on the scalp of a patient.