Podiatry Coding & Billing Alert

Question: My podiatrist made an incision in the area of a suspected sarcoma on the patient’s ankle. He then raised skin flaps on either side and isolated the tumor. The podiatrist excised and removed the sarcoma en bloc, with a margin of tissue around the tumor included. The mass, along with the surrounding tissues and margins, measures 4 cm. The podiatrist submitted the specimen for pathologic analysis. What CPT^® code should I report for this procedure?

New Hampshire Subscriber

Answer: You should report 27615 (Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; less than 5 cm) for this procedure.

Don’t miss: If your podiatrist specifies tumor removal, you must check the patient’s records for indications that the mass is musculoskeletal in origin, such as a reference to “soft tissue.” You should also check the documentation to make sure that the podiatrist includes a physical description of the tumor, as well as the diameter, the depth, the level of the tissue he removed, the closure type, and if he sent it to pathology.

When it comes to reporting the correct tumor removal procedure codes, you can ask yourself the following questions as you read through the medical documentation:

What was the exact size of the tumor? The excision and radical resection codes specify a certain size of tumor in their descriptor. For example, code 27615 is the correct choice here because the tumor was less than 5cm.

What was the depth of the tumor removal? Was it subcutaneous, subfascial, intramuscular, or deep? Note: Subcutaneous tissues are usually above deep fascia. When the podiatrist removes tissues below fascia, then he is getting into radical resections.

Did the podiatrist perform an excision or a radical resection? Note: One clue in your podiatrist’s documentation that would indicate a radical resection is the large area covered by the procedure.