How To Use CPT Code 28045

CPT 28045 describes the excision of a soft tissue tumor in the foot or toe, specifically in the subfascial area, that is less than 1.5 cm in size. 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 28045?

CPT 28045 can be used to describe the excision of a soft tissue tumor in the foot or toe that is located in the subfascial area and measures less than 1.5 cm in size. This code is used when a healthcare provider surgically removes the abnormal mass from within the muscles of the foot or toe and submits it to a laboratory for analysis.

2. Official Description

The official description of CPT code 28045 is: ‘Excision, tumor, soft tissue of foot or toe, subfascial (eg, intramuscular); less than 1.5 cm.’

3. Procedure

1. The healthcare provider prepares the patient for the procedure and administers anesthesia.
2. An incision is made over the soft tissue tumor, and the provider dissects down through the subcutaneous tissue to the muscle layer.
3. The provider identifies the tumor and completely excises it along with its margins.
4. The excised tumor specimen is then submitted to a laboratory for analysis to determine its nature.
5. The provider irrigates the area, checks for bleeding, removes any instruments, and closes the incision.

4. Qualifying circumstances

CPT 28045 is used for patients who require the excision of a soft tissue tumor in the foot or toe that is located in the subfascial area and measures less than 1.5 cm in size. The procedure must be performed by a healthcare provider and the tumor must be within the muscles of the foot or toe.

5. When to use CPT code 28045

CPT code 28045 should be used when a healthcare provider performs the excision of a soft tissue tumor in the foot or toe that is located in the subfascial area and measures less than 1.5 cm in size. This code should not be used for tumors in other locations or for tumors larger than 1.5 cm.

6. Documentation requirements

To support a claim for CPT 28045, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the excision of the soft tissue tumor
• Size and location of the tumor
• Date of the procedure
• Details of the procedure, including the incision, dissection, excision, and closure
• Submission of the excised tumor specimen to a laboratory for analysis
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 28045, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the size and location of the tumor, as well as the details of the procedure. CPT 28045 should not be reported with other codes unless additional procedures were performed during the same session. It is important to follow the specific guidelines provided by the payer when submitting claims for CPT 28045.

8. Historical information

CPT 28045 was added to the Current Procedural Terminology system on January 1, 1990. The code was later changed on January 1, 2010 to specify the subfascial location of the tumor.

9. Examples

1. A podiatrist performing the excision of a 1 cm soft tissue tumor located in the subfascial area of a patient’s foot.
2. An orthopedic surgeon removing a 1.2 cm soft tissue tumor from the subfascial area of a patient’s toe.
3. A foot and ankle specialist excising a 1.4 cm soft tissue tumor in the subfascial area of a patient’s foot.
4. A plastic surgeon performing the excision of a 1.3 cm soft tissue tumor located in the subfascial area of a patient’s toe.
5. An oncologist removing a 1.1 cm soft tissue tumor from the subfascial area of a patient’s foot.
6. A general surgeon excising a 1.5 cm soft tissue tumor in the subfascial area of a patient’s toe.
7. A dermatologist performing the excision of a 1.4 cm soft tissue tumor located in the subfascial area of a patient’s foot.
8. A vascular surgeon removing a 1.2 cm soft tissue tumor from the subfascial area of a patient’s toe.
9. An orthopedic oncologist excising a 1.3 cm soft tissue tumor in the subfascial area of a patient’s foot.
10. A plastic and reconstructive surgeon performing the excision of a 1.5 cm soft tissue tumor located in the subfascial area of a patient’s toe.