Overview of CPT Code 22115: Excision of soft tissue tumor, deep

Overview of CPT Code 22115: Excision of soft tissue tumor, deep

CPT Code 22115 refers to the surgical excision of a deep soft tissue tumor. This procedure is typically performed when a tumor is located beneath the skin and requires removal to prevent complications or further growth.

When CPT Code 22115 is Used?

This code is applicable in various clinical scenarios, including:

• Presence of a deep soft tissue tumor that is symptomatic or growing.
• Tumors that are suspected to be malignant and require histological examination.
• Tumors causing pain, discomfort, or functional impairment.

Symptoms Indicating This Procedure

Patients may report several symptoms that lead to the consideration of this procedure, including:

• A palpable mass or lump beneath the skin.
• Pain or tenderness in the area of the tumor.
• Changes in skin color or texture over the tumor.
• Limited range of motion if the tumor is near a joint.

Causes and Risk Factors

Understanding the causes and risk factors can help in identifying patients who may need this procedure.

• Genetic predisposition to certain types of tumors.
• Previous history of soft tissue tumors.
• Exposure to radiation or certain chemicals.
• Chronic inflammation or irritation in the area.

Diagnostic Tests Before Procedure

Several diagnostic tests may be performed to assess the tumor before excision, including:

• Ultrasound imaging to evaluate the size and depth of the tumor.
• MRI or CT scans for detailed imaging of soft tissue structures.
• Biopsy to determine the nature of the tumor.

Procedure Description

The excision procedure typically follows these steps:

• Patient is positioned comfortably and the area is sterilized.
• Local anesthesia is administered to numb the area.
• An incision is made over the tumor to access the tissue.
• The tumor is carefully excised along with a margin of healthy tissue.
• The incision is closed with sutures or staples, and a dressing is applied.

Preparation for the Procedure

Patients should follow these steps to prepare for the excision:

• Avoid eating or drinking for several hours before the procedure if sedation is planned.
• Discuss any medications with the healthcare provider, especially blood thinners.
• 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.
• Taking prescribed pain medications as needed.
• Monitoring for signs of infection such as increased redness or discharge.

Possible Complications

While generally safe, this procedure carries some risks, including:

• Infection at the surgical site.
• Excessive bleeding or hematoma formation.
• Scarring or changes in skin sensation.
• Recurrence of the tumor if not completely excised.

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Post-Procedure Follow-Up

Follow-up care is essential for monitoring recovery, typically involving:

• A follow-up appointment within 1-2 weeks to check the surgical site.
• Reviewing pathology results if a biopsy was performed.
• Further imaging or treatment if the tumor is found to be malignant.

Alternative Treatments

In some cases, alternative treatments may be considered, including:

• Observation for benign tumors that are not causing symptoms.
• Radiation therapy for inoperable tumors.
• Medications to manage symptoms or slow tumor growth.

Home Care Tips

Patients can follow these tips for effective home care:

• Keep the surgical area clean and dry.
• Avoid strenuous activities for a few weeks.
• Follow the healthcare provider's instructions regarding dressing changes.

Patient Education & Prevention

Educating patients on prevention and recurrence is vital, including:

• Regular skin checks for new or changing lesions.
• Awareness of family history of tumors.
• Healthy lifestyle choices to reduce cancer risk.

Billing and Coding Information

CPT Code: 22115

Category: Surgical Procedures

Common Modifiers:

• 50 - Bilateral procedure
• 59 - Distinct procedural service

Average Cost and Insurance Coverage

The cost of this procedure can vary widely based on several factors.

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

Related CPT Codes

• 22114 - Excision of benign skin lesion, face, ears, scalp, neck
• 19120 - Excision of Breast Lesion
• 11400 - Excision, benign skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
• 11406 - 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
• National Cancer Institute