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The CPT® Code 27616 refers to the radical resection of a tumor located in the soft tissue of the leg or ankle area, specifically when the tumor measures 5 cm or greater. Soft tissues encompass a variety of structures, including muscles, tendons, fat, blood vessels, lymph vessels, nerves, and the tissues that surround joints. Tumors that arise in these soft tissues can be classified as either benign or malignant. However, radical resection is predominantly indicated for malignant neoplasms, such as sarcomas, although there are instances where benign tumors or those of indeterminate nature may also necessitate this extensive surgical intervention. During the procedure, a skin incision is made directly over the tumor site in the lower leg or ankle region, or alternatively, a skin flap may be created and elevated to provide access. The surgeon meticulously dissects the overlying tissue to expose the tumor. The goal of radical resection is to remove the tumor en bloc, which means the tumor is excised along with a wide margin of surrounding healthy tissue to ensure complete removal of any cancerous cells. This procedure may involve the excision of all affected soft tissue, which can 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 the 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 prevent fluid accumulation. The surgical wound is typically closed in layers, and in some cases, separately reportable reconstructive procedures may be performed to restore the area. For smaller tumors measuring less than 5 cm, the appropriate code to use is 27615, while CPT® Code 27616 is specifically designated for tumors that are 5 cm or greater.
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The radical resection of a tumor in the soft tissue of the leg or ankle area, as described by CPT® Code 27616, is indicated for the following conditions:
The procedure for radical resection of a soft tissue tumor in the leg or ankle area involves several critical steps, which are outlined as follows:
Post-procedure care following a radical resection of a soft tissue tumor includes monitoring for complications, managing pain, and ensuring proper wound healing. Patients may require follow-up visits to assess the surgical site and to evaluate for any signs of recurrence or complications. The placement of drains, if utilized, will be monitored and managed accordingly. Recovery time may vary based on the extent of the surgery and the individual patient's health status. It is essential for patients to adhere to post-operative instructions provided by their healthcare team to facilitate optimal recovery.
| Short Descr | RESECT LEG/ANKLE TUM 5 CM/> | Medium Descr | RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE 5 CM/> | Long Descr | Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; 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) | 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 |
| 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. | 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.) | 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 | GC | This service has been performed in part by a resident under the direction of a teaching physician | KT | Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item | 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) | SA | Nurse practitioner rendering service in collaboration with a physician | SG | Ambulatory surgical center (asc) facility service | 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 |
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