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Radical resection is a surgical procedure primarily aimed at excising malignant neoplasms, such as sarcomas, from the soft tissue of the neck or anterior thorax. 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 involves 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 incision may vary based on the tumor's location; surgeons may opt to incise the skin directly over the tumor, create and elevate a skin flap, or make incisions along natural skin creases to optimize exposure. 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 can include muscles, nerves, and blood vessels, thereby ensuring comprehensive excision of the tumor. To confirm that the surgical margins are free of malignancy, a frozen section examination is performed, allowing for immediate pathological assessment. If any malignancy is detected at the margins, further tissue is excised until clear margins are achieved. Following the tumor removal, the surgeon repairs the muscle and soft tissues, and may perform a reconstructive procedure using various grafts or flaps, which can be reported separately. Additionally, drains may be placed as necessary, and the skin is closed in layers to promote optimal healing. For coding purposes, CPT® Code 21557 is utilized for radical resection of tumors measuring less than 5 cm, while CPT® Code 21558 is designated for tumors that are 5 cm or greater.
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Radical resection of a tumor in the soft tissue of the neck or anterior thorax is indicated for the following conditions:
The procedure for radical resection of a tumor in the soft tissue of the neck or anterior thorax involves several critical steps:
Post-procedure care following a radical resection includes monitoring for complications such as infection, bleeding, or fluid accumulation at the surgical site. Patients may require pain management and should be advised on activity restrictions to facilitate healing. Follow-up appointments are essential to assess the surgical site, remove any drains, and evaluate the need for further treatment, such as radiation or chemotherapy, depending on the pathology results. The recovery process may vary based on the extent of the surgery and the patient's overall health, and appropriate rehabilitation may be necessary to restore function in the affected area.
| Short Descr | RESECT NECK THORAX TUMOR<5CM | Medium Descr | RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX <5CM | Long Descr | Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; 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) | 2 - Payment restriction for assistants at surgery does not apply 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 |
| 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). | 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. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 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). | 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 | CR | Catastrophe/disaster related | 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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