How To Use CPT Code 21558

CPT code 21558 describes the radical resection of a soft tissue malignant tumor, such as a sarcoma, from the neck or anterior thorax that 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 21558?

CPT 21558 is used to describe the radical resection of a soft tissue malignant tumor, specifically in the neck or anterior thorax, that measures 5 cm or greater. This procedure involves the extensive removal of the tumor, including surrounding tissues suspected of involvement. It is important to note that this code is specifically for tumors of musculoskeletal origin, such as sarcomas.

2. Official Description

The official description of CPT code 21558 is: ‘Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax 5 cm or greater.’

3. Procedure

The procedure for CPT 21558 involves the following steps:

1. The patient is administered proper anesthesia, and the operative site is prepped and draped.
2. An incision is made in the area of the tumor.
3. Subplatysmal flaps are raised, and the tumor is isolated.
4. Any surrounding muscles are transected, and the deep aspect of the tumor and any attached muscle are dissected free of the fascia.
5. A margin of fibrofatty tissue is taken as the tumor is removed from the muscle and prepared for pathology.
6. A wide margin of additional tissue is excised to ensure complete removal of any remaining pathology in the surrounding structures.
7. The wound is irrigated, a drain is placed, and the incision is closed in layers.

It is important to note that a total excision diameter of 5 cm or greater is required to report this code.

4. Qualifying circumstances

CPT 21558 is applicable to patients with soft tissue malignant tumors, specifically sarcomas, in the neck or anterior thorax that measure 5 cm or greater. The procedure must involve the radical resection of the tumor, including wide margins of surrounding tissue. It is important to ensure that the tumor is of musculoskeletal origin and that the dimensions meet the criteria specified in the code description.

5. When to use CPT code 21558

CPT code 21558 should be used when performing the radical resection of a soft tissue malignant tumor, such as a sarcoma, in the neck or anterior thorax that measures 5 cm or greater. 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 21558, the following documentation is required:

• Patient’s diagnosis of a soft tissue malignant tumor, such as a sarcoma
• Specific details regarding the tumor’s location in the neck or anterior thorax
• Measurement of the tumor’s diameter, confirming it is 5 cm or greater
• Description of the procedure performed, including the radical resection of the tumor and wide margins of surrounding tissue
• Details of any additional tissues excised to ensure complete removal of pathology
• Documentation of anesthesia administration, prepping and draping of the operative site, and closure of the incision

7. Billing guidelines

When billing for CPT 21558, ensure that the procedure performed meets the specific criteria outlined in the code description. It is important to accurately document the details of the procedure and provide the necessary supporting documentation. Additionally, be aware of any specific billing guidelines or modifiers that may be required by payers.

8. Historical information

CPT 21558 was added to the Current Procedural Terminology system on January 1, 2010. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 21558

There are several similar codes to CPT 21558 that may be applicable in different scenarios. These include:

• CPT 21557: This code is used for the resection of a soft tissue malignant tumor, such as a sarcoma, from the neck or anterior thorax that measures less than 5 cm.
• CPT 21559: This code is used for the resection of a soft tissue malignant tumor, such as a sarcoma, from the neck or anterior thorax that measures greater than 5 cm, but also involves the removal of adjacent structures, such as bone or cartilage.
• CPT 21560: This code is used for the resection of a soft tissue malignant tumor, such as a sarcoma, from the neck or anterior thorax that measures greater than 5 cm and requires the reconstruction of adjacent structures, such as bone or cartilage.
• CPT 21561: This code is used for the resection of a soft tissue malignant tumor, such as a sarcoma, from the neck or anterior thorax that measures greater than 5 cm and requires the reconstruction of adjacent structures, such as bone or cartilage, with microvascular techniques.
• CPT 21562: This code is used for the resection of a soft tissue malignant tumor, such as a sarcoma, from the neck or anterior thorax that measures greater than 5 cm and requires the reconstruction of adjacent structures, such as bone or cartilage, with microvascular techniques and free flap.

9. Examples

1. A surgeon performs the radical resection of a 7 cm soft tissue sarcoma from the neck, ensuring wide margins of surrounding tissue are excised.
2. A patient presents with a 6 cm soft tissue malignant tumor in the anterior thorax, and a surgeon performs the radical resection, removing the tumor and surrounding tissues suspected of involvement.
3. A sarcoma measuring 5.5 cm is identified in the neck of a patient, and a surgeon performs the radical resection, excising the tumor and ensuring wide margins of surrounding tissue are removed.
4. A soft tissue malignant tumor measuring 8 cm is found in the anterior thorax of a patient, and a surgeon performs the radical resection, removing the tumor and adjacent structures suspected of involvement.