CPT® Code 21015

Radical resection is a surgical procedure primarily performed to excise malignant neoplasms, such as sarcomas, from the soft tissues of the face or scalp. This procedure may also be indicated for benign tumors or tumors of indeterminate nature that necessitate complete removal. The term "radical" signifies that the surgery aims to remove not only the tumor itself but also a significant margin of surrounding healthy tissue to ensure that all cancerous cells are eliminated. The approach to the resection can vary based on the tumor's location; surgeons may incise the skin directly over the tumor, create and elevate a skin flap, or make a series of incisions along natural skin creases to facilitate optimal exposure of the tumor. During the procedure, the surgeon meticulously dissects the soft tissue surrounding the tumor to fully expose it. The radical resection entails the removal of all affected soft tissue, which may include adjacent muscles, nerves, and blood vessels, thereby ensuring comprehensive excision of the malignancy. To confirm that the surgical margins are free of tumor cells, a frozen section examination is performed, which is separately reportable. If the margins are found to contain malignancy, further tissue is excised until clear margins are achieved. Following the tumor removal, the surgeon repairs the affected muscle and soft tissues, and may perform a reconstructive procedure using various grafts or flaps, which can be reported separately. Drains may be placed as necessary to manage any postoperative fluid accumulation, and the skin is closed in layers to promote optimal healing. For coding purposes, CPT® Code 21015 is used for radical resection of tumors measuring less than 2 cm, while CPT® Code 21016 is designated for tumors that are 2 cm or greater.