CPT® Code 21557

Radical resection is a surgical procedure primarily aimed at excising malignant neoplasms, such as sarcomas, from the soft tissue of the neck or anterior thorax. 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 involves 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 incision may vary based on the tumor's location; surgeons may opt to incise the skin directly over the tumor, create and elevate a skin flap, or make incisions along natural skin creases to optimize exposure. 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 can include muscles, nerves, and blood vessels, thereby ensuring comprehensive excision of the tumor. To confirm that the surgical margins are free of malignancy, a frozen section examination is performed, allowing for immediate pathological assessment. If any malignancy is detected at the margins, further tissue is excised until clear margins are achieved. Following the tumor removal, the surgeon repairs the muscle and soft tissues, and may perform a reconstructive procedure using various grafts or flaps, which can be reported separately. Additionally, drains may be placed as necessary, and the skin is closed in layers to promote optimal healing. For coding purposes, CPT® Code 21557 is utilized for radical resection of tumors measuring less than 5 cm, while CPT® Code 21558 is designated for tumors that are 5 cm or greater.