How To Use CPT Code 21630

CPT code 21630 describes the radical resection of the sternum, typically performed to treat a malignant tumor of the bone. 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 21630?

CPT 21630 is used to describe the radical resection of the sternum, which involves the complete removal of the breastbone. This procedure is typically performed to treat a malignant tumor of the sternum. It is an extensive surgical intervention that requires careful preparation and anesthesia.

2. Official Description

The official description of CPT code 21630 is: ‘Radical resection of sternum.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes a thoracotomy, which is an incision into the thorax or chest.
3. The serratus anterior muscle is identified and separated from the chest wall.
4. The provider uses a periosteal elevator to divide the attachments of the serratus anterior muscle to the first several ribs.
5. A sternal incision is made to visualize the sternum.
6. The tumor mass is excised, along with the sternum, subcutaneous tissues, affected pectoralis major muscle, cartilages of the first several ribs, and the anterior part of the pericardium.
7. The area is irrigated, and surgical mesh material is sutured to the chest wall to cover the defect.
8. The provider checks for bleeding, removes any instruments, and closes the incision in layers.

4. Qualifying circumstances

CPT 21630 is performed when a patient has a malignant tumor of the sternum that requires radical resection. This procedure is typically reserved for cases where less invasive treatments have been ineffective or are not feasible. It is important to note that this code is specific to the resection of the sternum and should not be used for other procedures or conditions.

5. When to use CPT code 21630

CPT code 21630 should be used when a provider performs a radical resection of the sternum to treat a malignant tumor. It is important to ensure that the procedure meets the criteria outlined in the official description and is not used for other purposes or conditions.

6. Documentation requirements

To support a claim for CPT 21630, the provider must document the following information:

• Patient’s diagnosis of a malignant tumor of the sternum
• Description of the procedure performed, including the specific tissues and structures removed
• Date of the procedure
• Details of the surgical technique used
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 21630, ensure that the procedure meets the criteria outlined in the official description. It is important to accurately document the details of the procedure and any associated complications or additional procedures. CPT code 21630 should not be reported with other codes unless there are distinct and separate procedures performed.

8. Historical information

CPT code 21630 was added to the Current Procedural Terminology system on January 1, 1990. It has undergone several changes, including being added and removed from the Inpatient Only (IPO) list for Medicare. The most recent change occurred in 2022 when it was added back to the IPO list.

9. Examples

1. A patient undergoes radical resection of the sternum to remove a malignant tumor.
2. A provider performs a radical resection of the sternum and uses surgical mesh for chest wall reconstruction.
3. A patient with a malignant tumor of the sternum undergoes a radical resection, including the removal of the pectoralis major muscle.
4. A provider performs a radical resection of the sternum and excises the tumor mass along with the cartilages of the first several ribs.
5. A patient undergoes radical resection of the sternum to treat a recurrent malignant tumor.
6. A provider performs a radical resection of the sternum and repairs the defect using surgical mesh.
7. A patient with a malignant tumor of the sternum undergoes a radical resection, including the removal of the anterior part of the pericardium.
8. A provider performs a radical resection of the sternum and checks for bleeding before closing the incision.
9. A patient undergoes radical resection of the sternum to achieve complete tumor removal.
10. A provider performs a radical resection of the sternum and ensures proper closure of the incision in layers.