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Radical resection of a tumor in the soft tissue of the leg or ankle area, as described by CPT® Code 27615, involves the surgical removal of a tumor that is less than 5 cm in size. Soft tissues encompass various structures, including muscles, tendons, fat, blood vessels, lymph vessels, nerves, and the tissues surrounding joints. Tumors found in these soft tissues can be either benign or malignant, with radical resection primarily indicated for malignant neoplasms, such as sarcomas. However, benign tumors or those of uncertain nature may also necessitate this extensive surgical approach. The procedure typically begins with a skin incision made directly over the tumor site in the lower leg or ankle, or alternatively, a skin flap may be created and elevated to access the tumor. The surgeon then meticulously dissects the overlying tissue to expose the tumor, which is excised en bloc, meaning the tumor is removed along with a wide margin of healthy surrounding tissue to ensure complete removal. This radical resection aims to eliminate all involved soft tissue, which may include critical structures such as muscles, nerves, and blood vessels. 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 all margins are confirmed to be clear of tumor cells. Post-surgery, drains may be placed as necessary to manage fluid accumulation, and the surgical wound can be closed in layers. In some cases, additional reconstructive procedures may be performed to restore the area after the tumor removal. This code, 27615, specifically applies to the radical resection of soft tissue tumors in the leg or ankle that measure less than 5 cm, while 27616 is designated for tumors that are 5 cm or greater.
© Copyright 2025 Coding Ahead. All rights reserved.
The radical resection of a soft tissue tumor in the leg or ankle area, as indicated by CPT® Code 27615, is performed under specific circumstances. The primary indications for this procedure include:
The procedure for radical resection of a soft tissue tumor in the leg or ankle area involves several critical steps, which are detailed as follows:
Post-procedure care following a radical resection of a soft tissue tumor in the leg or ankle area involves monitoring for complications and ensuring proper recovery. Patients may require pain management and should be observed for any signs of infection or complications related to the surgical site. The placement of drains, if utilized, will need to be monitored and managed appropriately. Follow-up appointments will be necessary to assess healing and to evaluate the surgical site for any signs of recurrence. Additionally, the patient may need physical therapy to regain strength and mobility in the affected area, depending on the extent of the surgery and the structures involved.
| Short Descr | RESECT LEG/ANKLE TUM < 5 CM | Medium Descr | RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE <5CM | Long Descr | Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; 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) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies 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 |
| RT | Right side (used to identify procedures performed on the right side of the body) | 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. | 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.) | 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) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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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| 2014-01-01 | Changed | Description Changed |
| 2010-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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