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The CPT® Code 21013 refers to the excision of a tumor located in the soft tissue of the face and scalp, specifically when the tumor is situated subfascially, which includes areas such as subgaleal or intramuscular locations. The term "soft tissue" encompasses various 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 procedure involves careful planning based on the tumor's location within the soft tissue of the face or scalp. The surgeon may make an incision over the tumor, create and elevate a skin flap, or utilize a series of incisions along natural skin creases to gain access to 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 frozen section may be performed to verify that all margins are free of tumor cells, which is crucial for ensuring that the tumor has been completely excised. After the tumor removal, drains may be placed as necessary, and the surgical wound is typically closed in layers to promote proper healing. For tumors located in the subcutaneous fat or connective tissue, different CPT codes are used based on the size of the mass, while CPT 21013 is specifically designated for subfascial tumors that are less than 2 cm in size.
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The excision of subfascial soft tissue tumors of the face and scalp, as described by CPT® Code 21013, is indicated for the following conditions:
The procedure for excising a subfascial soft tissue tumor involves several critical steps:
Post-procedure care following the excision of a subfascial soft tissue tumor includes monitoring for any signs of infection, managing pain, and ensuring proper wound healing. Patients may be advised to keep the surgical site clean and dry, and to follow specific instructions regarding activity restrictions to avoid strain on the incision. Follow-up appointments are typically scheduled to assess healing and to remove any sutures or drains if used. Additionally, patients may receive instructions on signs of complications that should prompt immediate medical attention.
| Short Descr | EXC FACE TUM DEEP < 2 CM | Medium Descr | EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL <2CM | Long Descr | Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 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) | 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 with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | 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 |
| 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. | 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). | 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). | 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). | 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) | E1 | Upper left, eyelid | E3 | Upper right, eyelid | 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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| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2010-01-01 | Added | - |
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