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Radical resection is a surgical procedure primarily performed to excise malignant neoplasms, such as sarcomas, from the soft tissues of the face or scalp. This procedure may also be indicated for benign tumors or tumors of indeterminate nature that necessitate complete removal. The term "radical" signifies that the surgery aims to remove not only the tumor itself but also a significant margin of surrounding healthy tissue to ensure that all cancerous cells are eliminated. The approach to the resection can vary based on the tumor's location; surgeons may incise the skin directly over the tumor, create and elevate a skin flap, or make a series of incisions along natural skin creases to facilitate optimal exposure of the tumor. During the procedure, the surgeon meticulously dissects the soft tissue surrounding the tumor to fully expose it. The radical resection entails the removal of all affected soft tissue, which may include adjacent muscles, nerves, and blood vessels, thereby ensuring comprehensive excision of the malignancy. To confirm that the surgical margins are free of tumor cells, a frozen section examination is performed, which is separately reportable. If the margins are found to contain malignancy, further tissue is excised until clear margins are achieved. Following the tumor removal, the surgeon repairs the affected muscle and soft tissues, and may perform a reconstructive procedure using various grafts or flaps, which can be reported separately. Drains may be placed as necessary to manage any postoperative fluid accumulation, and the skin is closed in layers to promote optimal healing. For coding purposes, CPT® Code 21015 is used for radical resection of tumors measuring less than 2 cm, while CPT® Code 21016 is designated for tumors that are 2 cm or greater.
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The radical resection of a tumor in the soft tissue of the face or scalp is indicated for the following conditions:
The procedure for radical resection of a tumor less than 2 cm involves several critical steps:
Post-procedure care following a radical resection includes monitoring for any signs of complications, such as infection or fluid accumulation. Patients may require pain management and should be advised on wound care to promote healing. Follow-up appointments are essential to assess the surgical site and ensure that there are no signs of recurrence. The physician may also discuss the results of the frozen section examination and any further treatment options if malignancy was detected at the margins. Rehabilitation may be necessary depending on the extent of tissue removed and the location of the surgery, particularly if muscles or nerves were involved in the resection.
| Short Descr | RESECT FACE/SCALP TUM < 2 CM | Medium Descr | RAD RESECTION TUMOR SOFT TISS FACE/SCALP < 2CM | Long Descr | Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 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) | 1 - Statutory payment restriction for assistants at surgery applies 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) | 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). | 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. | 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.) | 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. | 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. | 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.) | 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) | 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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| 2014-01-01 | Changed | Description Changed |
| 2010-01-01 | Changed | Code description changed. |
| 1991-01-01 | Added | First appearance in code book in 1991. |
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