Soft Tissue Tumors

Question:

I just started coding for Dermatology practice. I need some clarity on soft tissue tumor excisions. My physicians are telling me that when a soft tissue tumor excision is performed, the procedure includes all repairs, including a flap repair. If the physician removes a soft tissue tumor and does a flap on the same day, can I report the flap separately?

Answer:

All soft tissue tumor CPT codes 21011-21016 for the head, face, or scalp and 21552-21558 (neck and thorax) are reported based on anatomic location and centimeter size. These codes include direct closure (e.g., simple, intermediate, and complex repair). However, other types of closure may be separately reported, such as adjacent tissue transfer, split-thickness/full-thickness graft, muscle flap, etc., in addition to the soft tissue tumor excision.

*This response is based on the best information available as of 11/14/24.