Overview of CPT Code 21494: Excision of Tumor, Face or Neck

Overview of CPT Code 21494: Excision of Tumor, Face or Neck

CPT Code 21494 refers to the surgical excision of a tumor located on the face or neck. This procedure is performed to remove malignant or benign growths, ensuring clear margins to prevent recurrence.

When CPT Code 21494 is Used?

This code is applicable in various clinical scenarios, including:

• Presence of a suspicious or confirmed malignant tumor on the face or neck.
• Removal of benign tumors that cause discomfort or cosmetic concerns.
• Tumors that have changed in size, shape, or color, indicating potential malignancy.

Symptoms Indicating This Procedure

Patients may report the following symptoms that warrant this procedure:

• A noticeable lump or mass on the face or neck.
• Changes in the appearance of a mole or skin lesion.
• Pain, itching, or bleeding from the tumor site.

Causes and Risk Factors

Several factors can contribute to the development of tumors in the facial and neck regions.

• Sun exposure leading to skin cancer.
• Family history of skin cancer or other tumors.
• Previous skin lesions or cancers.
• Weakened immune system due to conditions like HIV or medications.

Diagnostic Tests Before Procedure

Prior to the excision, several diagnostic tests may be conducted:

• Biopsy to determine the nature of the tumor.
• Imaging studies such as ultrasound or CT scans to assess tumor size and depth.
• Blood tests to evaluate overall health and detect any underlying conditions.

Procedure Description

The excision procedure typically follows these steps:

• Patient is positioned comfortably and the area is cleaned and sterilized.
• Local anesthesia is administered to numb the area.
• A surgical incision is made around the tumor to remove it along with a margin of healthy tissue.
• The excised tissue is sent for pathological examination.
• The incision is closed with sutures or adhesive strips.

Preparation for the Procedure

Patients should follow these steps to prepare for the excision:

• Avoid blood-thinning medications such as aspirin or ibuprofen for at least a week prior.
• Discuss any allergies or medical conditions with the healthcare provider.
• Arrange for transportation home post-procedure if sedation is used.

Recovery and Aftercare

Post-procedure recovery typically involves:

• Resting for the first 24 hours after the procedure.
• Keeping the surgical site clean and dry.
• Applying prescribed ointments and taking pain medications as needed.
• Monitoring for signs of infection such as increased redness or discharge.

Possible Complications

While generally safe, this procedure may have risks, including:

• Infection at the surgical site.
• Scarring or changes in skin texture.
• Recurrence of the tumor if margins are not clear.

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Post-Procedure Follow-Up

Follow-up care is essential for monitoring recovery:

• A follow-up appointment is typically scheduled within 1-2 weeks to check the surgical site.
• Pathology results will be discussed during this visit.
• Additional treatments may be recommended based on pathology findings.

Alternative Treatments

In some cases, non-surgical options may be considered:

• Cryotherapy for superficial skin lesions.
• Topical chemotherapy for certain skin cancers.
• Laser therapy for benign growths.

Home Care Tips

Patients can follow these tips for effective home care:

• Keep the incision site clean and dry.
• Avoid sun exposure on the healing area.
• Follow the healthcare provider's instructions regarding activity restrictions.

Patient Education & Prevention

Educating patients on prevention is crucial:

• Regular skin checks for new or changing lesions.
• Use of sunscreen to protect against UV radiation.
• Avoiding tanning beds and excessive sun exposure.

Billing and Coding Information

CPT Code: 21494

Category: Surgical Procedures

Common Modifiers:

• 50 - Bilateral procedure
• 59 - Distinct procedural service

Average Cost and Insurance Coverage

The cost of the procedure can vary widely:

• Average cost ranges from $1,500 to $3,000 depending on complexity.
• Most insurance plans cover the procedure if deemed medically necessary.

Related CPT Codes

• 21495 - Removal of implant, shoulder
• 21497 - Repair of complex facial fracture

References and Sources

• American Academy of Dermatology
• National Cancer Institute