How To Use CPT Code 21016

CPT code 21016 describes the radical resection of a soft tissue malignant tumor, such as a sarcoma, from the face or scalp that measures 2 cm or greater. 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 21016?

CPT 21016 is used to describe the radical resection of a soft tissue malignant tumor, specifically from the face or scalp, that measures 2 cm or greater. This procedure involves the extensive removal of the tumor, including its surrounding area and anatomical structures suspected of involvement. The goal is to achieve complete excision of the tumor along with wide margins to ensure the removal of any potential malignancy.

2. Official Description

The official description of CPT code 21016 is: ‘Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp 2 cm or greater.’

3. Procedure

The procedure for CPT 21016 involves the following steps:

1. The patient is administered proper anesthesia, and the operative site (face or scalp) is prepped and draped.
2. A linear incision is made around the tumor site, typically following the natural skin creases.
3. The incision is extended deep and around the tumor to adequately expose the underlying anatomy.
4. Fascial, subplatysmal, or muscle flaps may be raised to further expose the tumor and surrounding structures.
5. Neurovascular structures in the area are identified and preserved.
6. The tumor is dissected from the surrounding tissue margin using a sharp scalpel.
7. An additional surrounding wide area of margin is also dissected and removed to ensure complete removal of any potential malignancy.
8. After the tumor and appropriate surrounding margin are excised, the incision is repaired in a layered fashion.

4. Qualifying circumstances

CPT 21016 is performed on patients with soft tissue malignant tumors, such as sarcomas, located on the face or scalp. The tumor must measure 2 cm or greater in diameter. The procedure requires the extensive removal of the tumor along with wide margins to ensure complete excision of any potential malignancy.

5. When to use CPT code 21016

CPT code 21016 should be used when a qualified healthcare professional performs a radical resection of a soft tissue malignant tumor measuring 2 cm or greater on the face or scalp. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 21016, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for radical resection of the tumor
• Details of the procedure, including the specific anatomical location and dimensions of the tumor
• Date of the procedure
• Start and end time of the procedure
• Steps taken during the procedure, such as incision, dissection, and removal of the tumor and surrounding margin
• Any complications or additional findings during the procedure
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 21016, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the details of the procedure and provide any necessary supporting documentation. There are no specific guidelines regarding reporting CPT 21016 with other codes.

8. Historical information

CPT 21016 was added to the Current Procedural Terminology system on January 1, 2010. On January 1, 2014, the code description was updated to include the term “malignant neoplasm” in addition to “tumor.”

9. Similar codes to CPT 21016

Five similar codes to CPT 21016 include:

• CPT 21015: This code is used for the resection of a soft tissue tumor, such as a sarcoma, from the face or scalp that measures less than 2 cm in diameter.
• CPT 21017: This code is used for the resection of a soft tissue tumor, such as a sarcoma, from the neck or anterior thorax that measures 2 cm or greater in diameter.
• CPT 21018: This code is used for the resection of a soft tissue tumor, such as a sarcoma, from the neck or anterior thorax that measures less than 2 cm in diameter.
• CPT 21019: This code is used for the resection of a soft tissue tumor, such as a sarcoma, from the posterior thorax, abdomen, or flanks that measures 2 cm or greater in diameter.
• CPT 21020: This code is used for the resection of a soft tissue tumor, such as a sarcoma, from the posterior thorax, abdomen, or flanks that measures less than 2 cm in diameter.

9. Examples

1. A surgeon performs a radical resection of a 3 cm soft tissue sarcoma from a patient’s scalp.
2. A plastic surgeon removes a 4 cm malignant tumor from a patient’s face using radical resection techniques.
3. An oncologist performs a wide excision of a 5 cm sarcoma from a patient’s scalp, ensuring complete removal of the tumor and surrounding margin.
4. A dermatologist performs a radical resection of a 2.5 cm malignant tumor from a patient’s face, achieving clear margins.
5. A maxillofacial surgeon removes a 6 cm sarcoma from a patient’s scalp using extensive resection techniques.
6. A head and neck surgeon performs a radical resection of a 3.5 cm soft tissue tumor from a patient’s face, ensuring complete removal of the tumor and surrounding margin.
7. A plastic surgeon removes a 4.5 cm malignant tumor from a patient’s scalp using radical resection techniques.
8. An oncologist performs a wide excision of a 2.8 cm sarcoma from a patient’s face, achieving clear margins.