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Official Description

Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); less than 5 cm

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 27619 refers to the excision of a tumor located in the soft tissue of the leg or ankle area, specifically when the tumor is subfascial, meaning it lies beneath the fascia, which is a connective tissue layer. This procedure is applicable for tumors that measure less than 5 centimeters in size. Soft tissues encompass a variety of 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 surgical approach may vary based on the tumor's location; for instance, the skin over the tumor may be incised directly, or a skin flap may be created and elevated to access the tumor. During the procedure, the overlying tissue is carefully dissected to expose the soft tissue mass, which is then 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, which is a critical step in ensuring the thoroughness of the excision. After the tumor is removed, drains may be placed as necessary, and the surgical wound is typically closed in layers to promote proper healing. For smaller tumors located in the subcutaneous fat or connective tissue, a different code, CPT® 27618, is used for excision when the tumor is less than 3 cm.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 27619 is indicated for the excision of soft tissue tumors located in the leg or ankle area that are subfascial and measure less than 5 cm. The following conditions may warrant this surgical intervention:

  • Soft Tissue Tumors These may be benign or malignant tumors found within the soft tissues of the leg or ankle, necessitating removal to prevent complications or further growth.
  • Well-Defined Margins Small malignant or indeterminate tumors that exhibit well-defined margins may also be excised to ensure complete removal and minimize the risk of recurrence.

2. Procedure

The procedure for excising a subfascial soft tissue tumor in the leg or ankle area involves several critical steps, which are outlined as follows:

  • Step 1: Preparation The patient is positioned appropriately, and the surgical site is prepared and draped in a sterile manner to minimize the risk of infection during the procedure.
  • Step 2: Incision An incision is made over the tumor site, which may involve directly incising the skin or creating and elevating a skin flap, depending on the tumor's location and depth.
  • Step 3: Dissection The overlying tissue is carefully dissected to expose the soft tissue mass. This step requires precision to avoid damaging surrounding structures such as nerves and blood vessels.
  • Step 4: Tumor Excision The tumor is excised along with a margin of healthy tissue to ensure complete removal. This margin is crucial for reducing the likelihood of residual tumor cells.
  • Step 5: Frozen Section Analysis If indicated, a frozen section may be performed during the procedure to assess the margins for tumor cells, ensuring that the excision is complete.
  • Step 6: Closure After the tumor has been removed, drains may be placed as needed to prevent fluid accumulation, and the surgical wound is closed in layers to promote optimal healing.

3. Post-Procedure

Post-procedure care following the excision of a subfascial soft tissue tumor includes monitoring the surgical site for signs of infection, managing pain, and ensuring proper wound healing. Patients may be advised on activity restrictions to avoid strain on the surgical area. Follow-up appointments are typically scheduled to assess the healing process and to discuss any further treatment if necessary, especially if the tumor was malignant. Additionally, patients should be informed about the signs of complications, such as increased swelling, redness, or discharge from the incision site, which would require prompt medical attention.

Short Descr EXC LEG/ANKLE TUM DEEP <5 CM
Medium Descr EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASCIAL <5CM
Long Descr Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); 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) 1 - Statutory payment restriction for assistants at surgery applies 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) P6B - Minor procedures - musculoskeletal
MUE 2
CCS Clinical Classification 160 - Other therapeutic procedures on muscles and tendons
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).
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.
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).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
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.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
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).
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
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)
SG Ambulatory surgical center (asc) facility service
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2011-01-01 Changed Medium description changed.
2010-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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