How To Use CPT Code 28046

CPT 28046 describes the radical resection of a tumor in the soft tissues of the foot or toe, measuring less than 3 cm. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 28046?

CPT 28046 can be used to describe the extensive excision of a tumor in the soft tissues of the foot or toe, suspected to be malignant, with a diameter of less than 3 cm. The procedure involves removing the tumor along with surrounding tissues to ensure complete removal of any diseased tissue.

2. Official Description

The official description of CPT code 28046 is: ‘Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; less than 3 cm.’

3. Procedure

1. The provider begins by making an incision in the area of the tumor and raising skin flaps on either side.
2. Next, the tumor is isolated and excised along with a margin of surrounding tissue to ensure complete removal.
3. The excised tumor is then submitted for pathologic analysis.
4. The provider irrigates the area, checks for bleeding, removes any instruments, and closes the incision.

4. Qualifying circumstances

CPT 28046 is used for patients with tumors in the soft tissues of the foot or toe, measuring less than 3 cm. These tumors are suspected to be malignant, such as sarcomas. The procedure is performed by a qualified healthcare professional and involves the radical resection of the tumor along with surrounding tissues.

5. When to use CPT code 28046

CPT code 28046 should be used when performing the radical resection of a tumor in the soft tissues of the foot or toe, with a diameter of less than 3 cm. It is important to carefully review the documentation to ensure the size and depth of the surgery align with the code description.

6. Documentation requirements

To support a claim for CPT 28046, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for tumor resection
• Size of the tumor and its location in the soft tissues of the foot or toe
• Description of the procedure performed, including the extent of tissue excised
• Date of the procedure
• Pathologic analysis results, if available
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 28046, ensure that the procedure meets the criteria outlined in the code description. It is important to accurately document the size of the tumor and the extent of tissue excised. Modifier 62 may be appended if two providers work together to perform the surgery. Confirm with the payer if they accept modifier 62 and any additional documentation requirements.

8. Historical information

CPT 28046 was added to the Current Procedural Terminology system on January 1, 1990. There have been several code changes since its addition, including updates to the description and inclusion of specific tumor types.

9. Examples

1. A surgeon performs the radical resection of a 2 cm sarcoma in the soft tissues of a patient’s toe.
2. A podiatrist removes a 1.5 cm tumor from the soft tissues of a patient’s foot.
3. An orthopedic surgeon excises a 2.5 cm tumor in the soft tissues of a patient’s toe.
4. A plastic surgeon performs the radical resection of a 2.8 cm sarcoma in the soft tissues of a patient’s foot, followed by plastic reconstruction.
5. A foot and ankle specialist removes a 2.2 cm tumor from the soft tissues of a patient’s toe.
6. A surgical oncologist performs the radical resection of a 2.7 cm sarcoma in the soft tissues of a patient’s foot.
7. A podiatric surgeon excises a 1.8 cm tumor from the soft tissues of a patient’s toe.
8. An orthopedic oncologist removes a 2.9 cm tumor in the soft tissues of a patient’s foot.
9. A plastic surgeon performs the radical resection of a 2.5 cm sarcoma in the soft tissues of a patient’s toe, followed by plastic reconstruction.
10. A foot and ankle specialist removes a 2.3 cm tumor from the soft tissues of a patient’s foot.