Part B Insider (Multispecialty) Coding Alert

Published on Wed Aug 08, 2012 PDF

Question: Our physician recently excised a soft tissue mass from the foot of a patient suffering from gout. What code would be appropriate for this excision?

Answer: The appropriate excision code depends largely on the size and depth of the excised tumor. CPT® provides specific codes for masses smaller or bigger than 1.5 cm in diameter that sit just underneath the skin (subcutaneous) or that are deep within the muscle or tissue (subfascial).

Remind your physician to indicate the size of the excised mass in the patient's record so that you can choose an accurate code. Based on specifications your podiatrist provides, select one of the following codes:

• 28039 -- Excision, tumor, soft tissue of foot or toe, subcutaneous; 1.5 cm or greater
• 28041 -- Excision, tumor, soft tissue of foot or toe, subfascial (e.g., intramuscular); 1.5 cm or greater
• 28043 -- Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cm
• 28045 -- Excision, tumor, soft tissue of foot or toe, subfascial (e.g., intramuscular); less than 1.5 cm.