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This 45-year-old male presents to the operating room with a painful mass of the right upper arm. General anesthesia was induced. Soft tissue dissection was carried through the proximal aspect of the teres minor muscle. Upon further dissection a large mass was noted just distal of the IGHL (inferior glenohumeral ligament), which appeared to be benign in nature. With blunt dissection and electrocautery, the 4 cm mass was removed en bloc and sent to pathology. The wound was irrigated, and repair of the teres minor with subcutaneous tissue was closed with triple-0 Vicryl. Skin was closed with double-0 Prolene in a subcuticular fashion. What CPT® code is reported? a. 23076-RT b. 11406-RT c. 23066-RT d. 23075-RT

Question

This 45-year-old male presents to the operating room with a painful mass of the right upper arm. General anesthesia was induced. Soft tissue dissection was carried through the proximal aspect of the teres minor muscle. Upon further dissection a large mass was noted just distal of the IGHL (inferior glenohumeral ligament), which appeared to be benign in nature. With blunt dissection and electrocautery, the 4 cm mass was removed en bloc and sent to pathology. The wound was irrigated, and repair of the teres minor with subcutaneous tissue was closed with triple-0 Vicryl. Skin was closed with double-0 Prolene in a subcuticular fashion. What CPT® code is reported? a. 23076-RT b. 11406-RT c. 23066-RT d. 23075-RT

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Solution

The correct CPT® code to report for this procedure is 23076-RT. This code is used for excision, tumor, soft tissue of upper arm or elbow area; subcutaneous. The RT modifier indicates that the procedure was performed on the right side of the body. The mass was located in the soft tissue of the upper arm, was removed en bloc, and the wound was repaired, which aligns with the description of the procedure covered by this code.

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