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The CPT® Code 21012 refers to the excision of a tumor located in the soft tissue of the face or scalp, specifically when the tumor measures 2 cm 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 that arise 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 procedure involves careful consideration of the tumor's location within the soft tissue, which may necessitate incising the skin over the tumor, creating and elevating a skin flap, or making a series of incisions along natural skin creases to facilitate exposure of the tumor. Once the overlying tissue is dissected, the soft tissue mass is exposed, allowing for the excision of the tumor along with a margin of healthy tissue to ensure complete removal. In some cases, a separately reportable frozen section may be performed during the procedure to confirm that all margins are free of tumor cells. After the excision, drains may be placed as needed, and the surgical wound is typically closed in layers to promote proper healing. For tumors located in the subcutaneous fat or connective tissue, CPT® Code 21011 is used for masses less than 2 cm, while CPT® Code 21012 is designated for those measuring 2 cm or greater. For tumors situated below the fascia, CPT® Code 21013 applies for masses less than 2 cm, and CPT® Code 21014 is used for those 2 cm or greater. It is important to note that subfascial soft tissue tumors include those found within muscle tissue and those located in the galea aponeurotica, which is a fibrous sheet of tissue that serves as an attachment point for specific muscle fibers in the scalp.
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The excision of soft tissue tumors in the face or scalp, as described by CPT® Code 21012, is indicated for various conditions, including:
The procedure for excising a soft tissue tumor of 2 cm or greater in the face or scalp involves several critical steps:
Post-procedure care for patients undergoing excision of a soft tissue tumor includes monitoring for complications such as infection or excessive bleeding. Patients are typically advised on wound care, including keeping the area clean and dry. Follow-up appointments are essential to assess healing and to remove sutures if non-absorbable materials were used. Patients may also be informed about signs of complications to watch for, such as increased redness, swelling, or discharge from the surgical site. Additionally, the results of any frozen section analysis will be discussed during follow-up visits to determine if further treatment is necessary.
| Short Descr | EXC FACE LES SBQ 2 CM/> | Medium Descr | EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2 CM/> | Long Descr | Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 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 | Office-based surgical procedure added to ASC list in CY 2008 or later without MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6A - Minor procedures - skin | MUE | 3 | CCS Clinical Classification | 170 - Excision of skin lesion |
| 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). | 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.) | 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. | 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. | 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. | 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) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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 | E1 | Upper left, eyelid | E2 | Lower left, eyelid | 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 | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | GX | Notice of liability issued, voluntary under payer policy | LT | Left side (used to identify procedures performed on the left side of the body) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | 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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| 2014-07-01 | Changed | Revised short descriptor to reflect greater than symbol ">". |
| 2013-01-01 | Changed | Short Descriptor changed. |
| 2011-01-01 | Changed | Short description changed. |
| 2010-01-01 | Added | - |
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