Overview of CPT Code 21616: Excision, benign lesion, neck

Overview of CPT Code 21616: Excision, benign lesion, neck

CPT Code 21616 refers to the surgical excision of a benign lesion located on the neck. This procedure is performed to remove non-cancerous growths that may cause discomfort, cosmetic concerns, or other complications.

When CPT Code 21616 is Used?

This code is applicable in various clinical scenarios.

• Presence of a benign tumor or cyst on the neck causing discomfort.
• Lesions that are cosmetically unappealing to the patient.
• Growths that are suspected to be benign but require histological examination.

Symptoms Indicating This Procedure

Patients may report several symptoms that lead to the decision for excision.

• Visible lump or bump on the neck.
• Pain or tenderness in the area of the lesion.
• Itching or irritation around the lesion.
• Changes in the size or appearance of the lesion.

Causes and Risk Factors

Understanding the causes and risk factors can help in prevention.

• Genetic predisposition to skin lesions.
• Previous skin injuries or infections.
• Chronic sun exposure leading to skin changes.
• Certain skin conditions like seborrheic keratosis.

Diagnostic Tests Before Procedure

Several tests may be conducted to confirm the need for excision.

• Physical examination of the lesion.
• Ultrasound imaging to assess the depth and characteristics of the lesion.
• Biopsy to determine the nature of the lesion if malignancy is suspected.

Procedure Description

The excision procedure follows a systematic approach.

• Patient is positioned comfortably and the area is cleaned.
• Local anesthesia is administered to numb the area.
• An incision is made around the lesion to excise it completely.
• The lesion is removed and sent for pathological examination if necessary.
• The incision is closed with sutures or adhesive strips.

Preparation for the Procedure

Proper preparation is essential for a smooth procedure.

• Avoid blood thinners and certain medications as advised by the physician.
• Inform the doctor about any allergies or medical conditions.
• Arrive at the facility with a clean neck area, free of lotions or creams.

Recovery and Aftercare

Post-procedure care is crucial for healing.

• Rest for the first 24 hours after the procedure.
• Keep the incision site clean and dry.
• Follow up for suture removal as directed by the physician.
• Use prescribed pain medications as needed.

Possible Complications

While complications are rare, they can occur.

• Infection at the incision site.
• Scarring or changes in skin pigmentation.
• Recurrence of the lesion if not completely excised.

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Post-Procedure Follow-Up

Regular follow-up is important for monitoring recovery.

• Schedule a follow-up appointment within 1-2 weeks post-procedure.
• Monitor for any signs of infection or complications.
• Discuss pathology results if the lesion was sent for analysis.

Alternative Treatments

There are non-surgical options available.

• Observation for small, asymptomatic lesions.
• Cryotherapy for superficial lesions.
• Topical treatments for certain benign skin conditions.

Home Care Tips

Simple home care can aid in recovery.

• Keep the area clean and avoid touching it unnecessarily.
• Apply ice packs to reduce swelling if needed.
• Follow a healthy diet to support healing.

Patient Education & Prevention

Education is key to preventing recurrence.

• Regular skin checks for new or changing lesions.
• Use sunscreen to protect skin from UV damage.
• Avoid excessive sun exposure and wear protective clothing.

Billing and Coding Information

CPT Code: 21616

Category: Surgical Procedures

Common Modifiers:

• 50 - Bilateral procedure
• 59 - Distinct procedural service

Average Cost and Insurance Coverage

Costs can vary based on several factors.

• Average cost ranges from $300 to $1,500 depending on complexity.
• Most insurance plans cover the procedure if deemed medically necessary.

Related CPT Codes

• 21615 - Excision of benign skin lesion, face, ears, scalp, neck, hands, feet, and genitalia; excised diameter over 4.0 cm.
• 11400 - Excision, benign skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
• 11401 - Excision, benign skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
• 11402 - Excision, benign skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.

References and Sources

• American Academy of Dermatology
• Mayo Clinic - Skin Lesions