How To Use CPT Code 21554

CPT code 21554 describes the excision of a tumor, specifically soft tissue of the neck or anterior thorax, that is subfascial (intramuscular) and measures 5 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 21554?

CPT 21554 is used to describe the excision of a tumor from the soft tissue of the neck or anterior thorax. This procedure specifically targets tumors that are subfascial (intramuscular) and measure 5 cm or larger in size. The surgeon makes an incision over the tumor, dissects into the muscle where the tumor is located, and removes it while protecting any surrounding nerves and ligating any feeding vessels or arteries. The wound is then irrigated, a drain may be placed, and the incision is closed in layers.

2. Official Description

The official description of CPT code 21554 is: ‘Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular) 5 cm or greater.’

3. Procedure

During the procedure for CPT 21554, the surgeon follows a step-by-step approach:

1. The surgeon makes a longitudinal incision over the tumor.
2. He dissects into the muscle where the tumor is located.
3. The surgeon identifies the mass and carefully dissects it off the muscles to which it is attached.
4. Any feeding vessels or arteries supplying the tumor are ligated and incised.
5. Surrounding nerves are protected during the dissection.
6. The wound is irrigated to ensure cleanliness.
7. A drain may be placed to prevent fluid buildup.
8. The incision is closed in layers to promote proper healing.

4. Qualifying circumstances

CPT 21554 is used for patients who require the excision of a tumor from the soft tissue of the neck or anterior thorax. The tumor must be subfascial (intramuscular) and measure 5 cm or greater in size. The procedure is typically performed by a surgeon who has determined that the tumor needs to be removed. The surgeon must ensure the protection of surrounding nerves and ligate any feeding vessels or arteries during the excision.

5. When to use CPT code 21554

CPT code 21554 should be used when a surgeon performs the excision of a tumor from the soft tissue of the neck or anterior thorax. This code is specifically for tumors that are subfascial (intramuscular) and measure 5 cm or larger. It is important to accurately document the size and location of the tumor to support the use of this code.

6. Documentation requirements

To support a claim for CPT 21554, the following documentation is required:

• Identification of the tumor and its location
• Measurement of the tumor to confirm it is 5 cm or larger
• Description of the surgical approach and technique used
• Documentation of the protection of surrounding nerves
• Ligation and incision of any feeding vessels or arteries
• Confirmation of wound irrigation and drain placement, if applicable
• Details of the closure technique used

7. Billing guidelines

When billing for CPT 21554, ensure that the excision is performed on a tumor that meets the specific criteria of being subfascial (intramuscular) and measuring 5 cm or greater. It is important to accurately document the size and location of the tumor to support the use of this code. Additionally, follow any specific billing guidelines provided by the payer to ensure proper reimbursement.

8. Historical information

CPT 21554 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 surgeon performs the excision of a 6 cm tumor from the soft tissue of a patient’s neck.
2. A tumor measuring 7 cm is removed from the anterior thorax of a patient by a surgeon.
3. A subfascial (intramuscular) tumor measuring 5 cm is excised from the neck of a patient by a surgeon.
4. A surgeon performs the excision of a 9 cm tumor from the soft tissue of a patient’s anterior thorax.
5. A tumor measuring 12 cm is removed from the neck of a patient by a surgeon.
6. A subfascial (intramuscular) tumor measuring 8 cm is excised from the anterior thorax of a patient by a surgeon.
7. A surgeon performs the excision of a 4 cm tumor from the soft tissue of a patient’s neck.
8. A tumor measuring 3 cm is removed from the anterior thorax of a patient by a surgeon.
9. A subfascial (intramuscular) tumor measuring 6 cm is excised from the neck of a patient by a surgeon.
10. A surgeon performs the excision of a 10 cm tumor from the soft tissue of a patient’s anterior thorax.