Soft Tissue Tumor Excision
[Lipoma / sebaceous cyst / soft tissue mass], [location], [X] cm
Same
Excision of soft tissue tumor, [location], [subcutaneous / subfascial]
[***, MD/DO]
[Resident/PA name]
[General / MAC / Local with sedation / Local]
Patient presents with a [slow-growing / symptomatic / enlarging] [lipoma / soft tissue mass / sebaceous cyst] at the [location] measuring approximately [X] cm. [Patient reports pain / cosmetic concern / concern for growth.] Imaging [not performed / ultrasound / MRI] [confirmed subcutaneous lipoma / showed heterogeneous mass]. No signs of malignancy. Decision made to proceed with surgical excision. Risks including infection, hematoma, seroma, nerve injury, and incomplete excision discussed. Consent obtained.
[Lipoma / sebaceous cyst / soft tissue mass], [X x Y] cm, [subcutaneous / superficial to fascia]. [Well-encapsulated / lobulated / not encapsulated]. [No involvement of underlying fascia or muscle.] [Specimen intact / fragmented during dissection].
The patient was positioned [supine / prone / lateral] and the [location] was prepped and draped in sterile fashion. [Local anesthesia infiltrated with 0.5% bupivacaine with epinephrine / General anesthesia administered.]
A [linear / elliptical] incision of [X] cm was made over the palpable [mass / lesion]. Dissection was carried through the subcutaneous tissue. The [lipoma / mass] was identified in the [subcutaneous / subfascial] plane and carefully dissected free using [sharp / blunt] dissection, maintaining the capsule intact. The specimen was excised in its entirety and sent to pathology.
Hemostasis was achieved with electrocautery. The wound was irrigated with saline. The subcutaneous layer was closed with [3-0 Vicryl]. Skin was closed with [3-0 Monocryl / staples / 4-0 Monocryl]. A sterile dressing was applied. Patient tolerated the procedure well.
None
Soft tissue mass sent to permanent pathology
Minimal
None
Patient taken to PACU in stable condition. Discharged to home.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Lipoma / soft tissue mass / sebaceous cyst], ***, *** cm
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Excision of soft tissue tumor, ***, [subcutaneous / subfascial]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [General / MAC / Local]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting with a [symptomatic / enlarging / cosmetically concerning] [lipoma / soft tissue mass] at *** measuring approximately *** cm. [Imaging confirmed subcutaneous lipoma / No imaging obtained for superficial lesion.] Decision made to proceed with excision. Risks including infection, hematoma, seroma, and incomplete excision were discussed. Informed consent obtained.
FINDINGS: [Lipoma / soft tissue mass / sebaceous cyst], *** x *** cm, [subcutaneous / superficial to fascia]. [Well-encapsulated / lobulated.] [No involvement of underlying fascia or muscle.]
DESCRIPTION OF PROCEDURE:
Patient positioned [supine / prone] and [location] prepped and draped in sterile fashion. [Local anesthesia with 0.5% bupivacaine with epinephrine infiltrated.] A [linear / elliptical] *** cm incision made over the mass. Dissection carried through subcutaneous tissue; [lipoma / mass] identified and dissected free [with capsule intact] using sharp and blunt technique. Specimen excised in entirety and sent to pathology. Hemostasis with electrocautery. Subcutaneous layer closed with 3-0 Vicryl; skin closed with [3-0 Monocryl / staples]. Sterile dressing applied. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Soft tissue mass to permanent pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to PACU in stable condition. Discharged to home.
Signed: .ME, .MYDEGREE
.TODAYVariants
Sebaceous / epidermoid cyst
Note whether capsule was excised intact vs. ruptured. Ruptured cysts require thorough irrigation of keratin material. Code identically to lipoma by size and location.
Recurrent lipoma / prior excision
Document prior surgical history and scar tissue encountered. Increased risk of incomplete excision. Consider imaging prior to re-excision for large recurrences.
Head and neck soft tissue mass
Proximity to facial nerve, parotid, or major vessels should be documented. Consider preoperative imaging.
Suspected or confirmed sarcoma
If the mass is firm, fixed, deep, or 5 cm or larger, do not shell it out. Obtain MRI and core-needle biopsy before resection per NCCN. When sarcoma is confirmed, orient the incision longitudinally along the limb axis so a later wide excision and any radiation field stay feasible, take a wide margin rather than enucleating along the pseudocapsule (which leaves positive margins), and place metallic clips in the resection bed to mark it for radiation planning. Unplanned excision of an occult sarcoma worsens outcomes and usually forces re-excision; refer to a sarcoma center.
Charting Tips
- Document exact location, size (measured), and depth (subcutaneous vs. subfascial)
- State whether capsule was excised intact (affects recurrence risk and pathology interpretation)
- Note proximity to named nerves, vessels, or structures and whether they were preserved
- Send all specimens to pathology regardless of presumed benign etiology
- Document closure layers.
- For masses ≥5 cm, deep-seated, firm/fixed, or rapidly growing, document whether preoperative MRI and biopsy were obtained per NCCN Soft Tissue Sarcoma guidelines. Unplanned excision of an occult sarcoma is associated with worse outcomes and may require re-excision.
- Record specimen dimensions in the operative note (match pathology report)
Documentation & Reimbursement Considerations
- Report Soft Tissue Tumor Excision as the primary service when it is the definitive operation performed.
- Reporting selection depends on tumor location and depth.
- Document depth explicitly: subcutaneous vs. subfascial vs. intramuscular.
- Pathologic exam is standard. Always send the specimen. If the frozen section or final pathology upgrades the diagnosis to malignant (sarcoma), the procedure may need to be re-coded or additional procedures (wide re-excision) planned. Document whether excision was with or without margins.
- Multiple soft tissue excisions at the same session: bill the largest/most complex lesion with the primary service; additional lesions at separate anatomic sites are billed with distinct-service reporting or the more specific separate-structure reporting. Do not use multiple-procedure reporting for same-code excisions at separate sites — CMS has largely deprecated multiple-procedure reporting and payers often reject it. Document each lesion separately with location, size, and depth.
- 90-day global period: routine wound checks, suture removal, and incision management are bundled. New lesion excision at a separate site within the global period uses unrelated-procedure reporting during the postoperative period.