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The CPT® Code 21933 refers to the excision of a tumor located in the soft tissue of the back or flank, specifically when the tumor is subfascial, meaning it is situated beneath the fascia, which is a layer of connective tissue. This procedure is applicable for tumors that measure 5 centimeters or greater. Soft tissues encompass a variety of structures, including subcutaneous fat, connective tissue, fascia, muscles, tendons, blood vessels, lymph vessels, nerves, and the tissues surrounding joints. Tumors found in these soft tissues can be either benign or malignant. Typically, benign tumors are treated through excision, while small malignant or indeterminate tumors may also be excised if they have well-defined margins. The excision process involves making a skin incision over the tumor or creating and elevating a skin flap. The surgeon then dissects the overlying tissue to expose the soft tissue mass, which is excised along with a margin of healthy tissue to ensure complete removal. In some cases, a frozen section may be performed to verify that all margins are free of tumor cells, which is a critical step in ensuring the thoroughness of the excision. After the tumor is removed, drains may be placed as necessary, and the surgical wound is closed in layers to promote proper healing. For smaller tumors in the subcutaneous fat or connective tissue, different CPT codes are used, such as 21930 for masses less than 3 cm and 21931 for masses 3 cm or greater. For tumors located below the fascia, CPT code 21932 is designated for masses less than 5 cm, while 21933 is specifically for those measuring 5 cm or greater, highlighting the importance of accurate coding based on tumor size and location.
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The excision of a soft tissue tumor in the back or flank is indicated for various conditions, particularly when the tumor is suspected to be benign or malignant. The following are specific indications for performing this procedure:
The procedure for excising a soft tissue tumor in the back or flank involves several critical steps, which are outlined as follows:
After the excision of the soft tissue tumor, the patient will require specific post-procedure care to ensure proper recovery. This may include monitoring for signs of infection, managing pain, and ensuring that the surgical site remains clean and dry. Patients may be advised on activity restrictions to avoid strain on the surgical area. Follow-up appointments will be necessary to assess healing and to discuss the results of any pathology reports if a frozen section was performed. Additionally, the healthcare provider may provide instructions regarding drain care if drains were placed during the procedure. Overall, the focus during the post-procedure phase is on promoting healing and preventing complications.
| Short Descr | EXC BACK TUM DEEP 5 CM/> | Medium Descr | EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/> | Long Descr | Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 2 | CCS Clinical Classification | 160 - Other therapeutic procedures on muscles and tendons |
| 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 47 | Anesthesia by surgeon: regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (this does not include local anesthesia.) note: modifier 47 would not be used as a modifier for the anesthesia procedures. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2011-01-01 | Changed | Short description changed. |
| 2010-01-01 | Added | - |
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