🩻 CPT 21555 — Excision, Tumor, Soft Tissue Of Neck Or Anterior Thorax, Subcutaneous; Less Than 3 Cm
Quick Reference
wRVU: 3.86 | Global Period: 090 | Assistant Payable: Yes, when medically necessary and payer requirements are met | Bilateral Indicator: 0 Rule: CPT 21555 reports open excision of a subcutaneous soft-tissue tumor of the neck or anterior thorax measuring less than 3 cm. The documented tissue plane must be subcutaneous, not subfascial or intramuscular. The Medicare bilateral indicator of 0 means the standard bilateral-surgery payment adjustment does not apply.1
📋 Clinical Description
CPT 21555 describes excision of a soft-tissue tumor located in the subcutaneous tissue of the neck or anterior thorax when the lesion measures less than 3 cm. The procedure includes the incision, dissection, removal of the lesion, hemostasis, and routine wound closure needed to complete the excision. The surgeon’s documentation should state the lesion location, greatest dimension, and superficial subcutaneous tissue plane. Pathology submission may occur when clinically indicated, but pathology interpretation is separately reportable by the pathologist when performed.2
CPT 21555 is selected by both depth and size. It differs from 21552, which describes a subcutaneous lesion measuring 3 cm or greater, and from 21556, which describes a subfascial or intramuscular lesion measuring less than 5 cm. A lesion extending through fascia or arising within muscle is not appropriately reported with 21555, even if its superficial component measures less than 3 cm. If the surgeon performs a radical resection rather than a standard excision, review 21557 or 21558 based on the documented extent and size of the resection.2
This procedure may be performed in the following clinical contexts:
- Superficial neck lipoma — The surgeon excises a documented subcutaneous lipomatous lesion from the neck measuring less than 3 cm. The operative record should establish that the lesion is superficial to the fascia.
- Anterior-thorax soft-tissue mass — A small superficial mass is removed from the subcutaneous tissue of the anterior thorax. Document the greatest dimension and avoid coding a confirmed neoplasm as a nonspecific mass when the provider establishes the diagnosis.
- Neoplasm of uncertain behavior — A small superficial soft-tissue lesion may be excised when the provider documents uncertain behavior. Do not assign uncertain behavior merely because final pathology is pending.
- Symptomatic localized mass — A palpable neck or anterior-thorax mass may be excised because of pain, enlargement, irritation, diagnostic uncertainty, or functional concern. The diagnosis code must reflect the confirmed condition or documented symptom as appropriate.
🔬 Anatomical & Procedural Considerations
| Variant | Mechanism | Key Notes |
|---|---|---|
| Subcutaneous tumor less than 3 cm | The lesion is located within superficial adipose or subcutaneous soft tissue and remains above the fascial plane. The surgeon removes the lesion through an open incision. | This is the depth and size category for 21555. Document the greatest dimension and the superficial tissue plane. |
| Subcutaneous tumor 3 cm or greater | The lesion remains superficial to the fascia but meets or exceeds 3 cm in greatest dimension. The surgical technique may otherwise resemble a smaller superficial excision. | Report 21552 rather than 21555 when the documented lesion measures 3 cm or greater. Do not reduce the reported size category because pathology measurement is smaller unless the final provider documentation supports that conclusion. |
| Subfascial or intramuscular tumor | The lesion extends deep to fascia, between muscle groups, or into muscle. Access requires dissection at a deeper tissue plane than a superficial subcutaneous excision. | Do not report 21555 for a subfascial lesion. Select 21556 for a lesion less than 5 cm or 21554 for a lesion 5 cm or greater when the documentation supports those codes. |
Clinical Pearl
The term “superficial” is not always sufficient documentation for 21555. The operative note should support a subcutaneous location and a greatest dimension of less than 3 cm. A lesion in or beneath fascia is coded by the subfascial family even when it is clinically palpable through the skin.2
✅ Procedure Includes
- Open incision and routine dissection required to access the documented subcutaneous soft-tissue tumor.
- Excision of one subcutaneous neck or anterior-thorax soft-tissue lesion measuring less than 3 cm.
- Routine hemostasis, layered closure, and dressing application integral to the excision.
- Submission of the tissue specimen for pathology when clinically appropriate.
- Usual postoperative care related to the excision during the 90-day global period.
❌ Excludes / Do Not Report Together
| Code | Description | Relationship |
|---|---|---|
| 21552 | Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater | Do not report with 21555 for the same lesion. Select the code based on the documented greatest lesion dimension. |
| 21554 | Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greater | Do not report with 21555 for the same lesion. 21554 requires a deep subfascial or intramuscular tissue plane and a lesion measuring 5 cm or greater. |
| 21556 | Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm | Do not report with 21555 for the same lesion. 21556 applies when the lesion is subfascial or intramuscular, regardless of its small size. |
| 21557 | Radical resection of tumor, soft tissue of neck or anterior thorax; less than 5 cm | Do not report in addition to 21555 for the same tumor. If the surgeon documents radical resection, use the appropriate radical-resection code instead of the routine-excision code. |
| 21558 | Radical resection of tumor, soft tissue of neck or anterior thorax; 5 cm or greater | Do not report in addition to 21555 for the same tumor. Tumor size, malignancy, and depth do not independently establish radical resection; the operative work must support it. |
Bundling Alert
CPT 21555 has a 90-day global period. Routine wound checks, dressing changes, suture removal, and usual postoperative management are included and should not be separately reported. A separately billable service during the global period requires documentation and a valid modifier, such as -24, -58, -78, or -79, that accurately describes the distinct circumstance.1
🌳 Code Tree — Surgery: Surgical Procedures On The Neck
CPT 21552-21558 Excision and Radical Resection of Soft-Tissue Tumors of the Neck or Anterior Thorax
│
├── 21552 Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater
│
├── 21554-21556 Excision, tumor, soft tissue of neck or anterior thorax
│ ├── 21552 Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater (Global: 090)
│ ├── 21554 Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greater (Global: 090)
│ ├── ▶▶ 21555 ◀◀ Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm ← YOU ARE HERE (Global: 090)
│ └── 21556 Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm (Global: 090)
│
└── 21557-21558 Radical resection of tumor, soft tissue of neck or anterior thorax
├── 21557 Radical resection of tumor, soft tissue of neck or anterior thorax; less than 5 cm
└── 21558 Radical resection of tumor, soft tissue of neck or anterior thorax; 5 cm or greater💰 RVU & Reimbursement Profile
| Component | Value |
|---|---|
| Work RVU | 3.86 |
| Global Period | 090 |
| Bilateral Indicator | 0 |
| Assistant Surgeon | 2 — Assistant at surgery may be paid |
| Co‑Surgeon | 0 — Co-surgery does not apply |
| Team Surgery | 0 — Team surgery does not apply |
| PC/TC Split | 0 — Physician service; PC/TC concept does not apply |
| Modifier -51 Exempt | No |
| Anesthesia | Separately reportable by the qualified anesthesia provider when medically necessary and documented |
Bilateral Billing Rules
Medicare assigns bilateral indicator 0 to 21555, so the usual 150% bilateral payment adjustment does not apply. Do not append -50 solely because lesions are removed from both sides. When separate lesions are excised, verify payer requirements for reporting multiple procedures or a distinct service and retain documentation identifying each lesion, location, and separate work.1
🏷️ Modifier Reference
| Modifier | Name | When to Apply |
|---|---|---|
| -24 | Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period | Append to an unrelated E/M service during the 90-day global period. The record must establish that the E/M service is unrelated to the excision and usual postoperative care. |
| -25 | Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service | Append to the E/M code when a significant, separately identifiable E/M service is performed on the same date. Do not append -25 to 21555. |
| -51 | Multiple Procedures | Use when multiple separately reportable procedures are performed during the same session, subject to payer instructions. Do not use it to separate services integral to the excision. |
| -52 | Reduced Services | Use when the physician electively reduces the planned service and documents the reduced work. Do not use it for an unanticipated discontinuation due to a patient safety concern. |
| -53 | Discontinued Procedure | Use when the procedure is discontinued because of extenuating circumstances or a threat to patient well-being. The operative report must identify the reason the procedure was stopped and the work completed. |
| -54 | Surgical Care Only | Use when the surgeon performs only the operative care and another physician provides postoperative management through a documented transfer-of-care arrangement. Payer-specific requirements apply. |
| -55 | Postoperative Management Only | Use when a physician provides only postoperative management after a qualifying transfer of care. This modifier represents the postoperative portion of the global package. |
| -56 | Preoperative Management Only | Use only when a physician provides preoperative management under a documented transfer-of-care arrangement. It is not used for routine preoperative work by the operating surgeon. |
| -58 | Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period | Use for a planned or staged related procedure when the documentation meets modifier requirements. An eligible staged procedure begins a new global period. |
| -59 | Distinct Procedural Service | Use only when a separate lesion, separate site, separate encounter, or independent service is documented and no more specific modifier applies. It must not be used to bypass edits for work integral to 21555. |
| -78 | Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period | Use for an unplanned related return to the operating or procedure room during the global period. The original 90-day global period continues. |
| -79 | Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period | Use for an unrelated procedure during the global period when the documentation supports no relationship to the original excision. A new global period begins when applicable. |
| -80 | Assistant Surgeon | May be reported by an assisting physician when an assistant is medically necessary and all payer requirements are met. Verify payer policy and retain operative documentation supporting the assistant’s role. |
| -81 | Minimum Assistant Surgeon | May be reported by a physician only when minimum assistant-surgeon services are medically necessary. Confirm payer requirements before billing. |
| -82 | Assistant Surgeon When Qualified Resident Surgeon Not Available | Use in a teaching setting only when a qualified resident surgeon is unavailable and documentation supports the modifier. Medicare teaching-physician rules apply. |
| -AS | Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery | Use for qualifying nonphysician practitioner assistant-at-surgery services when covered by the payer. The claim must meet scope-of-practice, credentialing, supervision, and medical-necessity requirements. |
🩺 Common ICD‑10‑CM Pairings
Primary Diagnosis Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| D17.0 | Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck | No | Use when the provider documents a benign lipomatous neoplasm in the head, face, or neck subcutaneous tissue. This diagnosis commonly aligns with the superficial tissue plane of 21555. |
| D17.1 | Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk | No | Use when a benign lipomatous neoplasm involves the anterior thorax or other trunk subcutaneous tissue. Confirm that the documented site is within the CPT code’s neck or anterior-thorax anatomic scope. |
| D21.0 | Other benign neoplasm of connective and other soft tissue of head, face and neck | No | Use when a benign connective or other soft-tissue neoplasm of the head, face, or neck is documented. Confirm superficial depth before selecting 21555. |
| D21.3 | Other benign neoplasm of connective and other soft tissue of thorax | No | Use for a documented benign connective or other soft-tissue neoplasm of the thorax. Do not use when provider documentation identifies a more specific histology or site. |
| D48.19 | Neoplasm of uncertain behavior of connective and other soft tissue | No | Use when the provider documents uncertain behavior. Do not assign uncertain behavior merely because final pathology is pending or the lesion has not yet been characterized. |
Secondary Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| D49.2 | Neoplasm of unspecified behavior of bone, soft tissue, and skin | No | Use only when the provider documents a neoplasm but does not establish whether it is benign, malignant, or of uncertain behavior. Query when the medical record supports more specific behavior. |
| R22.1 | Localized swelling, mass and lump, neck | No | Use when a neck mass is documented but no definitive diagnosis has been established. Do not report it in addition to a confirmed tumor diagnosis for the same lesion unless separately supported. |
| R22.2 | Localized swelling, mass and lump, trunk | No | Use when an anterior-thorax or other trunk mass is documented without a confirmed diagnosis. Once a definitive tumor diagnosis is established, use the diagnosis code reflecting that condition. |
Etiology / Complication
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| C49.0 | Malignant neoplasm of connective and soft tissue of head, face and neck | No | Use only for a documented malignant connective or soft-tissue neoplasm of the head, face, or neck. Verify that the surgeon performed routine excision rather than radical resection. |
| C49.3 | Malignant neoplasm of connective and soft tissue of thorax | No | Use only for a documented malignant connective or soft-tissue neoplasm of the thorax. The diagnosis does not independently determine the procedure code. |
Coding Specificity Reminder
Code the confirmed lesion behavior, histology, and anatomic site to the highest documented specificity. Do not code a diagnosis of malignancy based solely on concern for malignancy or a pathology specimen being submitted. When pathology changes the diagnosis after the procedure, follow outpatient and payer-specific diagnosis-reporting requirements and reconcile the final provider documentation.3
🏥 MS‑DRG Considerations
CPT 21555 does not independently assign an MS-DRG because inpatient MS-DRG assignment is based on the complete ICD-10-CM diagnoses, ICD-10-PCS procedure code(s), and discharge data. For an inpatient excision, PCS assignment depends on the actual tissue removed, body region, laterality when available, surgical approach, and whether the procedure meets the PCS definition of excision or resection. No nationwide NCD specifically governing CPT 21555 was identified, and no universally applicable LCD was identified in the Medicare Coverage Database review. The PFS Lookup tool provides Medicare payment data and indicators, including global period and surgical-payment information, whereas the MCD is used to identify any MAC- and jurisdiction-specific coverage policy, LCD, or billing-and-coding article.145
🔧 ICD‑10‑PCS Equivalents
| PCS Code | Full Description | Modality |
|---|---|---|
| 0JB40ZZ | Excision of Right Neck Subcutaneous Tissue and Fascia, Open Approach | Open excision |
| 0JB50ZZ | Excision of Left Neck Subcutaneous Tissue and Fascia, Open Approach | Open excision |
| 0JB60ZZ | Excision of Chest Subcutaneous Tissue and Fascia, Open Approach | Open excision |
| 0JB63ZZ | Excision of Chest Subcutaneous Tissue and Fascia, Percutaneous Approach | Percutaneous excision |
CPT 21555 is not mapped one-to-one to ICD-10-PCS. The PCS code must represent the actual body part, tissue depth, approach, laterality when available, device, and qualifier documented for the inpatient procedure. The open PCS examples are most analogous to an open superficial tumor excision, while a percutaneous code should be selected only when its PCS approach definition is met.5
PCS Character Analysis
| Position | Character | Value | Definition |
|---|---|---|---|
| 1 | Section | 0 | Medical and Surgical. This section contains operative procedures performed to treat disease or alter body structures. |
| 2 | Body System | J | Subcutaneous Tissue and Fascia. This body-system value is appropriate when the lesion is excised from the superficial subcutaneous/fascial tissue plane. |
| 3 | Root Operation | B | Excision. Excision means cutting out or off, without replacement, a portion of a body part. |
| 4 | Body Part | 4, 5, or 6 | 4 identifies right neck subcutaneous tissue and fascia, 5 identifies left neck subcutaneous tissue and fascia, and 6 identifies chest subcutaneous tissue and fascia. |
| 5 | Approach | 0 or 3 | 0 is open and 3 is percutaneous. Select the approach based on the operative technique documented, not on the CPT descriptor alone. |
| 6 | Device | Z | No device. Select another value only when a device remains in place at the conclusion of the procedure and the PCS table directs it. |
| 7 | Qualifier | Z | No qualifier. Use a diagnostic qualifier only when the procedure is performed for diagnostic purposes under PCS definitions. |
Root Operation Comparison
- Excision is appropriate when the surgeon removes a discrete portion of subcutaneous tissue or fascia, such as a small soft-tissue mass. It is the usual PCS root operation for a localized lesion removal.
- Resection means cutting out or off all of a body part. Do not select resection merely because the operative report uses the word “resection” in a nonspecific sense.
- Extraction is not the usual root operation for a soft-tissue tumor excision because extraction involves pulling or stripping out all or a portion of a body part by force.
📝 Coding Examples
Example 1
Clinical Scenario: A surgeon removes a 2.1 cm subcutaneous lipoma from the right lateral neck through an open incision. The operative report documents that the lesion is superficial to the cervical fascia, is completely excised, and is sent to pathology. Final pathology confirms a benign lipomatous neoplasm.
| Field | Code | Rationale |
|---|---|---|
| CPT | 21555 | The lesion is subcutaneous, located in the neck, and measures less than 3 cm. |
| PDx | D17.0 | The final diagnosis documents a benign lipomatous neoplasm of skin and subcutaneous tissue of the head, face, or neck. |
Note
The record must support both the less-than-3-cm size and superficial subcutaneous depth. Do not use a deep subfascial tumor code when the lesion remains above the fascia.
Example 2
Clinical Scenario: A surgeon excises a 2.8 cm superficial mass from the anterior thoracic subcutaneous tissue. The provider documents that pathology is pending and describes the lesion as a neoplasm of unspecified behavior. No fascial or muscular involvement is documented.
| Field | Code | Rationale |
|---|---|---|
| CPT | 21555 | The lesion is subcutaneous, in the anterior thorax, and measures less than 3 cm. |
| PDx | D49.2 | The provider identifies a neoplasm without establishing benign, malignant, or uncertain behavior. |
Warning
Do not assign D48.19 based only on pending pathology. Uncertain behavior requires provider documentation of uncertain behavior, not merely an unresolved diagnosis.
Example 3
Clinical Scenario: During the 90-day global period after a prior superficial neck tumor excision, the patient returns for a separately documented, unrelated excision of a small anterior-thorax subcutaneous mass. The same surgeon performs the second excision, and the record establishes that it is unrelated to the previous neck procedure.
| Field | Code | Rationale |
|---|---|---|
| CPT | 21555--79 | -79 identifies an unrelated procedure by the same physician during the global period of the original procedure. |
| PDx | R22.2 | The provider documents an anterior-thorax mass without a confirmed tumor diagnosis at the time of the second procedure. |
Global period reminder
An unrelated procedure reported with -79 begins a new global period when applicable. The documentation must establish that the subsequent lesion and procedure are unrelated to the original excision.
⚠️ Common Coding Pitfalls
- Pitfall 1: Reporting 21555 for a lesion measuring exactly 3 cm or larger. A subcutaneous lesion measuring 3 cm or greater is reported with 21552, not 21555.
- Pitfall 2: Selecting 21555 when the lesion is beneath fascia or intramuscular. A subfascial lesion requires selection from the deep-tissue code family, regardless of its superficial appearance.
- Pitfall 3: Coding the lesion size from an unsupported estimate. The surgeon should document the greatest dimension; when documentation is conflicting, query before choosing a size-dependent procedure code.
- Pitfall 4: Reporting 21555 with 21552, 21554, or 21556 for the same tumor. These codes are mutually exclusive alternatives based on size and tissue depth.
- Pitfall 5: Appending -50 because multiple lesions are removed from opposite sides. The PFS bilateral indicator is 0, so the standard Medicare bilateral adjustment does not apply.
- Pitfall 6: Separately billing routine wound care during the 90-day global period. Routine postoperative evaluation and management are included unless a documented, distinct service supports a valid modifier.
📎 Sources
1 Centers for Medicare & Medicaid Services. Medicare Physician Fee Schedule Look-Up Tool and CY 2026 PFS Relative Value Files, 2026. CPT 21555: work RVU 3.86, total nonfacility RVU 13.85, global period 090, and bilateral-surgery indicator 0.
2 American Medical Association. Current Procedural Terminology, CPT 2026 Professional Edition. CPT family 21552, 21554, 21555, 21556, 21557, and 21558.
3 Centers for Medicare & Medicaid Services. ICD-10-CM Official Guidelines for Coding and Reporting and FY 2026 ICD-10-CM code set, 2026.
4 Centers for Medicare & Medicaid Services. Medicare Coverage Database Search, reviewed August 10, 2026. No nationwide NCD or universally applicable LCD specifically governing CPT 21555 was identified; verify MAC-specific LCDs and billing-and-coding articles for the applicable jurisdiction.
5 Centers for Medicare & Medicaid Services. FY 2026 ICD-10-PCS Official Guidelines for Coding and Reporting and ICD-10-PCS Table 0JB, 2026.
Sources listed above correspond to superscript citations throughout this note. Verify all Medicare payment figures against your current CMS PFS Lookup tool and applicable MAC LCD prior to claim submission. Please use the latest AAPC/AHIMA Coding Books to verify each code within this note.