Outpatient Facility Coding Alert

Question: If the physician documents removal of a tumor from the foot, how should I code for the procedure?

Alabama Subscriber

Answer: You must check the patient’s records for indications that the mass is musculoskeletal in origin, such as a reference to “soft tissue.” Tumor removal codes fall under the 20000 code series. You must also check for indications of the size of the excised tumor since CPT^® provides codes for specific sizes, as follows:

• 28039 — Excision, tumor, soft tissue of foot or toe, subcutaneous; 1.5 cm or greater
• 28041 — … subfascial (e.g., intramuscular); 1.5 cm or greater
• 28043 — … subcutaneous; less than 1.5 cm
• 28045 — … subfascial (e.g., intramuscular); less than 1.5 cm
• 28046 — Radical resection of tumor (e.g., sarcoma), soft tissue of foot or toe; less than 3 cm
• 28047 — … 3 cm or greater.

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