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Radical resection of a tumor, specifically a soft tissue tumor located in the back or flank, is a surgical procedure denoted by CPT® Code 21935. This procedure is indicated for tumors that are less than 5 cm in size and may involve various types of soft tissues, including muscles, tendons, fat, blood vessels, lymph vessels, nerves, and the tissues surrounding joints. Soft tissue tumors can be classified as benign or malignant, with radical resection primarily performed for malignant neoplasms, such as sarcomas. However, there are instances where benign tumors or those of indeterminate nature may also necessitate a radical resection. The surgical approach typically begins with making a skin incision directly over the tumor or creating and elevating a skin flap. Following this, the overlying subcutaneous and soft tissues are carefully dissected to expose the tumor mass. The procedure aims to remove the tumor en bloc, which means the tumor is excised along with a wide margin of surrounding healthy tissue to ensure complete removal. This radical approach may involve the excision of adjacent muscles, nerves, and blood vessels, depending on the tumor's location and extent. To confirm that all cancerous cells have been removed, a separately reportable frozen section may be performed during the procedure. If any margins are found to contain malignancy, additional tissue will be excised until all margins are confirmed to be free of tumor cells. Post-surgery, drains may be placed as necessary, and the surgical wound can be closed in layers, or additional reconstructive procedures may be performed if required. For tumors measuring 5 cm or greater, CPT® Code 21936 should be utilized instead.
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Radical resection of a soft tissue tumor in the back or flank is indicated for the following conditions:
The procedure for radical resection of a soft tissue tumor involves several critical steps:
Post-procedure care for patients undergoing radical resection of a soft tissue tumor includes monitoring for any signs of complications, such as infection or fluid accumulation. Patients may require follow-up visits to assess the surgical site and ensure proper healing. The placement of drains, if utilized, will be monitored and managed accordingly. Additionally, the patient may need to follow specific instructions regarding activity restrictions and wound care to promote optimal recovery. The overall recovery time may vary depending on the extent of the surgery and the patient's individual health status.
| Short Descr | RESECT BACK TUM < 5 CM | Medium Descr | RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK <5CM | Long Descr | Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; less than 5 cm | 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) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | 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) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 160 - Other therapeutic procedures on muscles and tendons |
| 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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.) | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2014-01-01 | Changed | Description Changed |
| 2010-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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