How To Use CPT Code 21935

CPT code 21935 describes the radical resection of a soft tissue malignant tumor, such as a sarcoma, from the back or flank. 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 21935?

CPT 21935 is used to describe the radical resection of a soft tissue malignant tumor, specifically in the back or flank region. This procedure involves the extensive removal of the tumor, including surrounding tissue margins suspected of involvement. The diameter of the tumor and the required margins must measure less than 5 cm.

2. Official Description

The official description of CPT code 21935 is: ‘Radical resection of tumor (eg, sarcoma), soft tissue of back or flank less than 5 cm.’

3. Procedure

The procedure for CPT 21935 involves the following steps:

1. After administering proper anesthesia, the provider performs a curvilinear incision around the tumor site, typically following the natural skin creases.
2. The incision is extended deep and around the tumor to adequately expose the underlying anatomy.
3. Fascial, subfascial, and/or muscle flaps may be raised to further expose the tumor and surrounding structures.
4. Neurovascular structures in the area are identified and preserved.
5. Using a sharp scalpel, the provider carefully dissects the tumor from the surrounding tissue margin and removes it.
6. To ensure complete removal and rule out further malignancy, an additional wide area of margin is dissected and removed.
7. Once the tumor and appropriate surrounding margin have been excised, the incision is repaired in a layered fashion.

It is important to note that a total excision diameter of less than 5 cm is reportable with this code.

4. Qualifying circumstances

CPT 21935 is applicable to patients with soft tissue malignant tumors, such as sarcomas, located in the back or flank region. The procedure requires the radical resection of the tumor along with wide margins of surrounding tissue. The diameter of the tumor and the margins must measure less than 5 cm.

5. When to use CPT code 21935

CPT code 21935 should be used when a provider performs a radical resection of a soft tissue malignant tumor in the back or flank region, with a total excision diameter of less than 5 cm. 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 21935, the provider must document the following information:

• Patient’s diagnosis and the need for radical resection of the tumor
• Details of the procedure, including the incision technique, extent of dissection, and removal of the tumor and surrounding margin
• Date of the procedure
• Start and end time of the procedure
• Size of the tumor and margins
• Any complications or additional findings during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 21935, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the size of the tumor and margins, as well as any additional findings or complications. There are no specific guidelines regarding reporting CPT 21935 with other codes.

8. Historical information

CPT 21935 was added to the Current Procedural Terminology system on January 1, 1990. Since then, there have been two code changes. On January 1, 2010, the code description was updated to include the term “malignant neoplasm.” On January 1, 2014, the code description was further revised to specify “soft tissue” and “less than 5 cm.”

9. Similar codes to CPT 21935

Five similar codes to CPT 21935 include:

• CPT 21936: This code is used for the radical resection of a soft tissue malignant tumor in the back or flank region, with a total excision diameter of 5 cm or greater.
• CPT 21930: This code is used for the excision of a soft tissue tumor, such as a sarcoma, in the back or flank region, with a total excision diameter of less than 5 cm.
• CPT 21931: This code is used for the excision of a soft tissue tumor, such as a sarcoma, in the back or flank region, with a total excision diameter of 5 cm or greater.
• CPT 21932: This code is used for the excision of a soft tissue tumor, such as a sarcoma, in the back or flank region, with a total excision diameter of less than 3 cm.
• CPT 21933: This code is used for the excision of a soft tissue tumor, such as a sarcoma, in the back or flank region, with a total excision diameter of 3 cm or greater but less than 5 cm.

9. Examples

1. A surgeon performs a radical resection of a 4 cm soft tissue sarcoma from the back of a patient.
2. A surgical oncologist removes a 3.5 cm malignant tumor from the flank of a patient, ensuring wide margins of surrounding tissue are excised.
3. A plastic surgeon performs a radical resection of a 2 cm sarcoma from the back of a patient, including the necessary surrounding margin.
4. An orthopedic surgeon excises a 4.5 cm soft tissue tumor from the flank of a patient, ensuring complete removal with wide margins.
5. A general surgeon performs a radical resection of a 3.8 cm malignant tumor from the back of a patient, taking care to remove the appropriate surrounding margin.
6. A surgical oncologist removes a 4.2 cm sarcoma from the flank of a patient, ensuring wide margins of surrounding tissue are excised.
7. A plastic surgeon performs a radical resection of a 1.5 cm malignant tumor from the back of a patient, including the necessary surrounding margin.