How To Use CPT Code 21015

CPT code 21015 describes the radical resection of a tumor, specifically in the soft tissue of the face or scalp that is 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 21015?

CPT 21015 is used to describe the radical resection of a tumor in the soft tissue of the face or scalp that is smaller than 2 cm in size. This procedure is performed to ensure that the tumor has not spread to the surrounding area. It is typically done when the tumor is known or suspected to be malignant, or cancerous.

2. Official Description

The official description of CPT code 21015 is: ‘Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp less than 2 cm.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision over the area of the tumor, usually in line with the skin creases for facial tumors.
3. The incision is extended into the deep tissues around the tumor.
4. Flaps of soft tissue and/or muscle are raised to adequately expose the underlying anatomy.
5. Neurovascular structures in the area are identified and preserved.
6. The tumor is separated from the surrounding tissue, localized, and dissected from the surrounding tissue margin.
7. A wide area or margin of surrounding tissue is dissected and removed to rule out further malignancy.
8. The dissected tumor and tissue margin are submitted for laboratory analysis.
9. Bleeding is checked and any instruments are removed.
10. The incision is closed in layers.

4. Qualifying circumstances

CPT 21015 is performed on patients with tumors in the soft tissue of the face or scalp that are smaller than 2 cm. The procedure is typically done when the tumor is known or suspected to be malignant. It is important to ensure that the tumor has not spread to the surrounding area, and a radical resection is performed to achieve this.

5. When to use CPT code 21015

CPT code 21015 should be used when a radical resection of a tumor in the soft tissue of the face or scalp that is smaller than 2 cm is performed. It is important to accurately document the size of the tumor and ensure that it meets the criteria for this specific code.

6. Documentation requirements

To support a claim for CPT 21015, the following documentation is required:

• Patient’s diagnosis and the need for radical resection of the tumor
• Size of the tumor (less than 2 cm)
• Details of the procedure, including the incision, dissection, and removal of the tumor and surrounding tissue margin
• Documentation of any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21015, ensure that the procedure meets the criteria for this specific code. It is important to accurately document the size of the tumor and the details of the procedure. CPT code 21015 should not be reported with other codes unless additional procedures or complications arise during the surgery.

8. Historical information

CPT code 21015 was added to the Current Procedural Terminology system on January 1, 1991. There have been a few changes to the code over the years, including updates to the description and the addition of notes.

9. Examples

1. A patient undergoes a radical resection of a 1.5 cm sarcoma in the soft tissue of their face.
2. A provider performs a radical resection of a 1 cm tumor in the scalp to rule out malignancy.
3. A patient with a suspected malignant tumor in the soft tissue of their face undergoes a radical resection to remove the tumor and surrounding tissue margin.
4. A provider performs a radical resection of a 1.8 cm sarcoma in the soft tissue of the scalp.
5. A patient undergoes a radical resection of a 1.2 cm tumor in the face to ensure complete removal.
6. A provider performs a radical resection of a 1.7 cm sarcoma in the soft tissue of the scalp.
7. A patient with a suspected malignant tumor in the soft tissue of their face undergoes a radical resection to remove the tumor and surrounding tissue margin.
8. A provider performs a radical resection of a 1.3 cm tumor in the scalp to rule out malignancy.
9. A patient undergoes a radical resection of a 1.6 cm sarcoma in the soft tissue of their face.
10. A provider performs a radical resection of a 1.4 cm tumor in the face to ensure complete removal.