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Official Description

Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 5 cm or greater

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 23073 refers to the excision of a tumor located in the soft tissue of the shoulder area, specifically when the tumor is subfascial, meaning it lies beneath the fascia. 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 making an incision in the skin over the tumor or creating and elevating a skin flap, followed by dissection of the overlying tissue to expose the soft tissue mass. The tumor is excised 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. After the excision, drains may be placed as necessary, and the surgical wound is closed in layers. It is important to note that for tumors located in the subcutaneous fat or connective tissue, different CPT codes are applicable based on the size of the mass, while tumors that are subfascial and measure 5 cm or greater are specifically coded with 23073.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 23073 is indicated for the excision of soft tissue tumors located in the shoulder area that are subfascial and measure 5 cm or greater. The following conditions may warrant this procedure:

  • Soft Tissue Tumors These may be benign or malignant tumors found within the soft tissues of the shoulder area.
  • Well-Defined Margins Small malignant or indeterminate tumors may also be excised if they have well-defined margins, making them suitable for surgical removal.

2. Procedure

The procedure for excising a subfascial soft tissue tumor in the shoulder area involves several key steps:

  • Incision The surgeon begins by making an incision in the skin directly over the tumor or creating a skin flap that is elevated to provide access to the underlying tissue.
  • Tissue Dissection Once the incision is made, the overlying tissue is carefully dissected to expose the soft tissue mass. This step is crucial to ensure that the tumor is adequately visualized and accessible for excision.
  • Tumor Excision The tumor is excised along with a margin of healthy tissue surrounding it. This margin is important to ensure that any potential cancerous cells are removed, reducing the risk of recurrence.
  • Frozen Section Analysis If necessary, a frozen section may be performed during the procedure to confirm that the margins of the excised tumor are free of tumor cells, ensuring complete removal.
  • Drain Placement After the tumor has been excised, drains may be placed as needed to prevent fluid accumulation in the surgical site.
  • Wound Closure Finally, the surgical wound is closed in layers to promote proper healing and minimize scarring.

3. Post-Procedure

Post-procedure care for patients who have undergone excision of a subfascial soft tissue tumor includes monitoring for any signs of infection, managing pain, and ensuring proper wound care. Patients may be advised to keep the surgical site clean and dry, and to follow specific instructions regarding activity restrictions to promote healing. Follow-up appointments may be necessary to assess the surgical site and to discuss the results of any pathology reports, particularly if a frozen section was performed during the procedure.

Short Descr EXC SHOULDER TUM DEEP 5 CM/>
Medium Descr EXC TUMOR SOFT TISSUE SHOULDER SUBFASCIAL 5 CM/>
Long Descr Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 5 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) 1 - 150% payment adjustment for bilateral procedures applies.
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 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 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.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
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.
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).
81 Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.
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
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
GW Service not related to the hospice patient's terminal condition
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
Date
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2011-01-01 Changed Short description changed.
2010-01-01 Added -
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