How To Use CPT Code 21936

CPT 21936 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 21936?

CPT 21936 is used to describe the radical resection of a soft tissue malignant tumor, specifically in the back or flank area. This procedure involves the extensive removal of the tumor, including its surrounding area and anatomical structures suspected of involvement. The tumor must have a diameter of 5 cm or greater, and the margins required for removal must also measure 5 cm or more.

2. Official Description

The official description of CPT code 21936 is: ‘Radical resection of tumor (eg, sarcoma), soft tissue of back or flank 5 cm or greater.’

3. Procedure

The procedure for CPT 21936 involves the following steps:

1. Administer proper anesthesia and perform the usual prep and drape of the operative site.
2. Create a curvilinear incision around the tumor site, mostly in line with the skin creases.
3. Extend the incision deep and around the tumor, raising fascial, subfascial, and/or muscle flaps if necessary to expose the underlying anatomy.
4. Identify and preserve neurovascular structures in the area.
5. Locate the tumor and use a sharp scalpel to dissect it from the surrounding tissue margin.
6. Remove the tumor and an additional surrounding wide area of margin to rule out further malignancy.
7. Ensure satisfactory radical removal of the tumor and appropriate surrounding margin.
8. Repair the incision in a layered fashion.

A total excision diameter of 5 cm or more is reportable with this code.

4. Qualifying circumstances

CPT 21936 is applicable to patients with soft tissue malignant tumors, such as sarcomas, that require radical resection. The procedure is performed on the back or flank area, and the tumor must have a diameter of 5 cm or greater. The extensive removal of the tumor and its surrounding area is necessary to qualify for this code.

5. When to use CPT code 21936

CPT code 21936 should be used when a soft tissue malignant tumor, such as a sarcoma, is being radically resected from the back or flank area. The tumor must have a diameter of 5 cm or greater, and the procedure must involve the removal of the tumor along with wide margins of surrounding tissue.

6. Documentation requirements

To support a claim for CPT 21936, the following documentation is required:

• Patient’s diagnosis and indication for radical resection
• Specific details of the procedure, including the location of the tumor and the dimensions of the tumor and margins
• Date of the procedure
• Start and end time of the procedure
• Details of the surgical approach and techniques used
• Any complications or additional procedures performed
• Signature of the performing healthcare professional

7. Billing guidelines

When billing for CPT 21936, ensure that the procedure meets the criteria for radical resection of a soft tissue malignant tumor from the back or flank area. The tumor must have a diameter of 5 cm or greater, and the procedure must involve the removal of the tumor along with wide margins of surrounding tissue. There are no specific guidelines regarding reporting this code with other codes.

8. Historical information

CPT 21936 was added to the Current Procedural Terminology system on January 1, 2010. The code underwent a change on January 1, 2014, with the description being updated to include ‘malignant neoplasm’ in addition to ‘tumor.’

9. Similar codes to CPT 21936

Five similar codes to CPT 21936 include:

• CPT 21935: This code is used for the resection of a soft tissue malignant tumor from the back or flank, but with dimensions smaller than 5 cm.
• CPT 21930: This code is used for the resection of a soft tissue malignant tumor from the extremities, excluding hand and feet.
• CPT 21931: This code is used for the resection of a soft tissue malignant tumor from the hand or finger.
• CPT 21932: This code is used for the resection of a soft tissue malignant tumor from the foot or toe.
• CPT 21933: This code is used for the resection of a soft tissue malignant tumor from the head or neck.

9. Examples

1. A surgeon performs a radical resection of a 7 cm soft tissue sarcoma from the back of a patient.
2. A surgical oncologist removes a 6 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 an 8 cm sarcoma from the back, including the removal of surrounding tissue to rule out further malignancy.
4. An orthopedic surgeon removes a 5.5 cm soft tissue malignant tumor from the flank, ensuring wide margins of surrounding tissue are excised.
5. A general surgeon performs a radical resection of a 6.5 cm sarcoma from the back, taking care to remove the tumor along with a wide area of surrounding tissue.
6. A surgical oncologist removes a 7.5 cm malignant tumor from the flank, ensuring wide margins of surrounding tissue are excised to achieve radical resection.
7. A plastic surgeon performs a radical resection of a 9 cm sarcoma from the back, including the removal of surrounding tissue to ensure complete removal of the tumor.
8. An orthopedic surgeon removes a 5.8 cm soft tissue malignant tumor from the flank, ensuring wide margins of surrounding tissue are excised.
9. A general surgeon performs a radical resection of a 6.2 cm sarcoma from the back, taking care to remove the tumor along with a wide area of surrounding tissue.