How To Use CPT Code 27616

CPT 27616 describes the extensive surgical removal of a soft tissue tumor and surrounding tissues in the leg or ankle area, measuring 5 cm or more. 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 27616?

CPT 27616 can be used to describe the radical resection of a soft tissue tumor in the leg or ankle area, measuring 5 cm or greater. This code is used when the surgeon removes the tumor along with wide margins of normal tissue from one or more layers of soft tissue around the lesion to completely excise the tumor.

2. Official Description

The official description of CPT code 27616 is: ‘Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; 5 cm or greater.’ This code is specifically for the extensive surgical removal of a soft tissue tumor and surrounding tissues in the leg or ankle area, measuring 5 cm or more.

3. Procedure

1. The surgeon makes an incision in the skin of the leg or ankle over the tumor.
2. The tumor is removed along with wide margins of normal tissue from one or more layers of soft tissue around the lesion.
3. Closure of the incision is performed.

4. Qualifying circumstances

CPT 27616 is used for the radical resection of a soft tissue tumor in the leg or ankle area, measuring 5 cm or greater. This procedure is typically performed for sarcomas, which are malignant tumors of connective tissue origin that can occur in the bone or soft tissues anywhere in the body.

5. When to use CPT code 27616

CPT code 27616 should be used when the surgeon performs an extensive surgical removal of a soft tissue tumor in the leg or ankle area, measuring 5 cm or more. It is important to carefully review the documentation to determine the size and depth of the surgery before selecting this code.

6. Documentation requirements

To support a claim for CPT 27616, the surgeon must document the following information:

• Size of the tumor
• Depth of the surgery
• Extent of the resection, including the removal of wide margins of normal tissue
• Description of the closure performed

7. Billing guidelines

When billing for CPT 27616, ensure that the surgery meets the criteria for an extensive resection of a soft tissue tumor in the leg or ankle area, measuring 5 cm or more. It is important to review the documentation carefully to determine if any modifiers are necessary. Additionally, consider the reimbursement guidelines for surgeries involving two or more surgeons, as modifier 62 may be applicable.

8. Historical information

CPT 27616 was added to the Current Procedural Terminology system on January 1, 2010. There was a code change on January 1, 2014, which updated the description to include ‘malignant neoplasm’ in addition to ‘sarcoma’.

9. Examples

1. A surgeon performs an extensive resection of a soft tissue tumor measuring 7 cm in the leg of a patient.
2. A patient undergoes radical resection of a sarcoma in the ankle area, with the tumor measuring 6 cm.
3. A surgeon removes a soft tissue tumor measuring 8 cm in the leg, along with wide margins of normal tissue.
4. An extensive resection is performed on a 5 cm soft tissue tumor in the ankle area, completely excising the tumor.
5. A patient undergoes radical resection of a sarcoma measuring 9 cm in the leg, with the removal of wide margins of normal tissue.
6. A surgeon performs an extensive resection of a soft tissue tumor measuring 6 cm in the ankle area, ensuring complete excision of the tumor.
7. A patient undergoes radical resection of a sarcoma in the leg, with the tumor measuring 7 cm and the removal of wide margins of normal tissue.
8. An extensive resection is performed on a 5 cm soft tissue tumor in the ankle area, completely removing the tumor and surrounding tissues.
9. A surgeon removes a soft tissue tumor measuring 8 cm in the leg, along with wide margins of normal tissue to ensure complete excision.
10. A patient undergoes radical resection of a sarcoma measuring 9 cm in the ankle area, with the removal of wide margins of normal tissue to ensure complete excision.