Summary & Overview
CPT 27614: Excision of Deep Soft Tissue Lesion, Leg or Ankle
CPT code 27614 represents the surgical excision of a lesion from the muscle or subfascial tissues of the leg or ankle with submission of the specimen for pathologic evaluation. This code is used when a provider removes a deep soft tissue lesion to establish a diagnosis and guide subsequent management. Nationally, accurate coding for procedures like 27614 matters for clinical documentation, appropriate payment, quality measurement, and tracking of diagnostic surgical care for lower-extremity soft tissue lesions.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on the clinical use of 27614, where the procedure is typically performed, and benchmarking implications for payers and providers. The publication outlines expected service settings, common clinical indications for diagnostic excisional procedures of deep soft tissue in the leg or ankle, and what to consider for claims and documentation when submitting this code.
The report provides benchmarks and policy-relevant context (e.g., utilization patterns and payment considerations) and clarifies where input data are not available. The material is written for a national audience of clinicians, coding professionals, and policy analysts interested in surgical diagnostic procedures of the lower extremity.
Billing Code Overview
CPT code 27614 describes the excision of a lesion from the muscle or subfascial tissues of the leg or ankle. The procedure includes removal of the lesion and submission of the excised tissue for pathologic evaluation. The clinical purpose is diagnostic, performed to determine the nature of a suspicious or indeterminate soft tissue lesion.
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Service type: Surgical excision for diagnostic biopsy of deep soft tissue
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Typical site of service: Hospital outpatient department, ambulatory surgery center, or hospital inpatient setting depending on clinical complexity and patient needs
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 48-year-old patient presents to an orthopedic clinic with a firm, deep-seated, painless mass in the posterior compartment of the lower leg progressively enlarging over several months. Imaging with MRI demonstrates a 2.5 cm intramuscular lesion in the gastrocnemius consistent with a soft-tissue tumor or atypical lipomatous lesion. The orthopedic surgeon schedules an excisional biopsy of the lesion under regional or general anesthesia in an ambulatory surgery center or hospital operating room. The procedure involves a skin incision, dissection through subcutaneous tissue to the fascia, and excision of the lesion from the muscle or subfascial plane. The specimen is submitted for pathologic evaluation to establish a definitive diagnosis (e.g., benign lipoma, nodular fasciitis, or soft-tissue sarcoma). Postoperative care includes wound closure, dressing, short observation for recovery, pain control, and pathology-driven follow-up planning. Typical sites of service include the hospital outpatient department or ambulatory surgical center. The service type is surgical excision of a deep lesion for diagnostic purposes in the leg/ankle region.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
LT | Left side | When the procedure was performed on the left leg or left ankle |
RT |