How To Use CPT Code 21557

CPT code 21557 describes the radical resection of a tumor in the soft tissues of the neck or anterior thorax, with a diameter of less than 5 cm. 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 21557?

CPT 21557 is used to describe the extensive excision of a tumor or mass in the soft tissues of the neck or anterior thorax, suspected to be malignant. The procedure involves removing the tumor along with surrounding tissues, with the diameter of the tumor and its margins measuring less than 5 cm.

2. Official Description

The official description of CPT code 21557 is: ‘Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax less than 5 cm.’

3. Procedure

During the procedure, the healthcare provider makes an incision in the area of the tumor after the patient is appropriately prepped and anesthetized. Subplatysmal flaps are raised, and the tumor is isolated. Any muscles surrounding the mass are divided, and the deep aspect of the tumor and any attached muscle are dissected free of the fascia. The provider removes the tumor from the muscle and prepares it for pathologic analysis, taking a margin of fibrofatty tissue. To ensure that no diseased tissue remains in the surrounding structures, the provider excises a wide margin of additional tissue. The wound is irrigated, a drain is placed, and the incision is closed in layers.

4. Qualifying circumstances

CPT 21557 is performed when there is a suspected malignant tumor in the soft tissues of the neck or anterior thorax, such as a sarcoma. The diameter of the tumor and its margins must measure less than 5 cm. The procedure requires the removal of surrounding tissues to ensure complete removal of any diseased tissue.

5. When to use CPT code 21557

CPT code 21557 should be used when performing a radical resection of a tumor in the soft tissues of the neck or anterior thorax, with a diameter of less than 5 cm. It is important to ensure that the tumor is suspected to be malignant and that the procedure involves the removal of surrounding tissues to ensure complete removal of any diseased tissue.

6. Documentation requirements

To support a claim for CPT 21557, the healthcare provider must document the following information:

• Patient’s diagnosis and the suspicion of malignancy
• Size of the tumor and its margins
• Details of the procedure, including the incision, dissection, removal of the tumor and surrounding tissues, and closure of the incision
• Any additional procedures performed, such as placement of a drain
• Pathologic analysis of the tumor
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 21557, ensure that the procedure meets the criteria of radical resection of a tumor in the soft tissues of the neck or anterior thorax, with a diameter of less than 5 cm. It is important to document the suspicion of malignancy and the removal of surrounding tissues. There are no specific guidelines regarding reporting CPT 21557 with other codes.

8. Historical information

CPT 21557 was added to the Current Procedural Terminology system on January 1, 1990. There have been two code changes since its addition, with the most recent change occurring on January 1, 2014.

9. Similar codes to CPT 21557

Five similar codes to CPT 21557 include:

• CPT 21558: Radical resection of tumor, e.g., sarcoma, soft tissue of neck or anterior thorax, 5 cm or greater.
• CPT 21555: Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm.
• CPT 21556: Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater.
• CPT 21559: Radical resection of tumor, e.g., sarcoma, soft tissue of neck or thorax, 5 cm or greater.
• CPT 21560: Radical resection of tumor, e.g., sarcoma, soft tissue of neck or thorax, less than 5 cm.

9. Examples

1. A patient undergoes radical resection of a 4 cm sarcoma in the soft tissues of the neck.
2. A healthcare provider performs extensive excision of a 3 cm tumor in the anterior thorax.
3. A patient undergoes radical resection of a 2 cm suspected malignant tumor in the soft tissues of the neck.
4. A sarcoma measuring 4.5 cm is removed from the soft tissues of the anterior thorax.
5. A healthcare provider performs radical resection of a 3.5 cm tumor in the neck, suspected to be malignant.
6. An extensive excision is performed on a 2.5 cm tumor in the soft tissues of the anterior thorax.
7. A patient undergoes radical resection of a 1.5 cm sarcoma in the neck.
8. A healthcare provider performs extensive excision of a 4.8 cm tumor in the anterior thorax.
9. A 2.3 cm suspected malignant tumor is removed from the soft tissues of the neck.
10. A sarcoma measuring 3.7 cm is excised from the soft tissues of the anterior thorax.