CPT® Code 21558

Radical resection is a surgical procedure primarily performed to excise malignant neoplasms, such as sarcomas, but it may also be indicated for benign tumors or tumors of indeterminate nature. This procedure is particularly relevant when dealing with tumors located in the neck or anterior thorax, where careful planning and execution are crucial due to the complex anatomy and the presence of vital structures. The approach to radical resection can vary based on the tumor's location; surgeons may choose to incise the skin directly over the tumor, create and elevate a skin flap, or make a series of incisions along natural skin creases to optimize exposure. The goal of the procedure is to remove not only the tumor itself but also all surrounding soft tissue that may be involved, which can include muscles, nerves, and blood vessels. This ensures that the tumor is excised with a wide margin of healthy tissue, minimizing the risk of residual cancerous cells. To confirm that the margins are free of tumor cells, a frozen section examination is performed during the procedure. If any malignancy is detected at the margins, additional 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 if necessary. Drains may be placed to manage any postoperative fluid accumulation, and the skin is closed in layers to promote optimal healing. For coding purposes, CPT® Code 21558 is specifically designated for radical resection of tumors that are 5 cm or greater in size, while CPT® Code 21557 is used for tumors less than 5 cm.