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Radical resection of a tumor in the scapula, as described by CPT® Code 23210, is a surgical procedure primarily aimed at removing malignant neoplasms, although it may also be indicated for benign tumors or tumors of indeterminate nature. The procedure begins with the creation of a skin incision directly over the tumor site on the scapula, or alternatively, a skin flap may be elevated to provide access. During the operation, the surgeon meticulously dissects the overlying tissue to expose the tumor. The radical resection involves the complete removal of all bone and cartilage in the scapula that is affected by the tumor, ensuring that the tumor is excised en bloc, which means it is removed in one piece along with a wide margin of healthy surrounding tissue. This approach is critical to minimize the risk of residual tumor cells remaining in the body. The procedure also necessitates the excision of all involved soft tissue, which can include muscles, tendons, fat, blood vessels, lymph vessels, nerves, and any tissues surrounding the joints that may be affected by the tumor. To confirm that the surgical margins are free of tumor cells, a separately reportable frozen section may be performed during the procedure. If any margins are found to contain malignancy, additional tissue will be excised until clear margins are achieved. Post-surgery, drains may be placed as necessary to manage fluid accumulation, and the surgical wound can be closed in layers, or additional reconstructive procedures may be performed if required.
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Radical resection of a tumor in the scapula is indicated for the following conditions:
The procedure for radical resection of a tumor in the scapula involves several critical steps:
After the radical resection of the tumor in the scapula, patients may require specific post-procedure care to ensure proper recovery. This includes monitoring for any signs of infection or complications related to the surgical site. The placement of drains, if utilized, will need to be managed to prevent fluid accumulation. Patients may experience pain and discomfort, which can be addressed with appropriate pain management strategies. Follow-up appointments will be necessary to assess healing and to review the results of the frozen section analysis. If additional reconstructive procedures were performed, further follow-up may be required to evaluate the outcomes of those interventions. Overall, the recovery process will vary based on the extent of the surgery and the individual patient's health status.
| Short Descr | RESECT SCAPULA TUMOR | Medium Descr | RADICAL RESECTION TUMOR SCAPULA | Long Descr | Radical resection of tumor; scapula | 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) | 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 | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 142 - Partial excision bone |
This is a primary code that can be used with these additional add-on codes.
| 20932 | Add-on Code MPFS Status: Active Code APC N ASC N1 Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (List separately in addition to code for primary procedure) | 20933 | Add-on Code MPFS Status: Active Code APC N ASC N1 Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (List separately in addition to code for primary procedure) | 20934 | Add-on Code MPFS Status: Active Code APC N ASC N1 Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (List separately in addition to code for primary procedure) |
| 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. | 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 | 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) |
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| 2010-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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