Summary & Overview
CPT 28041: Excision of Intrinsic Foot/Toe Muscle Mass, Specimen ≥1.5 cm
CPT code 28041 represents the surgical excision of an abnormal mass arising within the intrinsic muscles of the foot or toe, with submission of a specimen 1.5 cm or greater for laboratory analysis. This code is used to document and bill for definitive removal and pathological evaluation of soft-tissue lesions in the foot, a procedure relevant to podiatry, orthopedic foot and ankle surgery, and general surgery practices. Nationally, accurate use of this code supports appropriate tracking of surgical management of foot masses and ensures alignment with payer documentation and coverage rules.
Key payers commonly included in commercial and public analyses are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, typical sites of service, and which procedures this code captures. The publication provides benchmarks for utilization and common billing patterns where available, highlights policy or coding guidance that affects claim adjudication, and summarizes clinical considerations relevant to specimen handling and pathological submission.
Readers will learn how CPT code 28041 is defined, where it fits in surgical foot and toe care, and what documentation elements commonly accompany claims. Data not available in the input is explicitly noted where applicable.
Billing Code Overview
CPT code 28041 describes surgical excision of an abnormal mass located within the intrinsic muscles of the foot or toe. The procedure includes removal of the lesion and submission of the specimen, 1.5 cm or greater, to a laboratory for gross and/or pathological analysis to determine its nature.
Service Type
- Surgical excision of soft tissue mass within the foot or toe musculature.
Typical Site of Service
- Outpatient surgical suite, ambulatory surgery center, or hospital operating room, depending on clinical complexity and patient needs.
Clinical & Coding Specifications
Clinical Context
A 54-year-old patient presents to an outpatient podiatry or orthopedic clinic with a progressively enlarging, tender mass deep within the intrinsic muscles of the plantar aspect of the foot near the metatarsal heads. The mass measures over 1.5 cm on ultrasound and is suspected to be a soft-tissue tumor (e.g., intramuscular lipoma, ganglion cyst, or benign neoplasm). After history, focused physical exam, and imaging (ultrasound and/or MRI) to define size, depth, and relation to neurovascular structures, the patient is scheduled for an excision of the intramuscular foot mass under monitored anesthesia care or local/regional anesthesia in an ambulatory surgical center or hospital outpatient department. In the procedure, the provider makes a surgical incision, dissects through subcutaneous tissue to the involved muscle belly, excises the mass intact when possible, achieves hemostasis, and submits the specimen (≥1.5 cm) to the pathology laboratory for histologic analysis. Postoperative care includes wound closure, dressing, brief recovery monitoring, and postoperative instructions for weight-bearing and follow-up for pathology results and possible further oncologic management if malignant features are reported.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When reporting only the surgeon's professional service separate from technical facility charges (rare for surgical procedures billed by surgeon). |