Surgical removal of a subcutaneous soft tissue tumor of the foot or toe measuring 1.5 cm or greater, with specimen submitted for pathologic analysis.

Verified May 8, 2026 · 6 sources ↓

Medicare: $476.63
Work RVU: 5.28
Global, days: 90
Region: Foot & ankle

Drawn from CMSEmednyAAPCMdclarityPayerprice

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 6 cited references ↓

Measured size of the excised specimen documented in the operative note — must be 1.5 cm or greater to support 28039 over 28043
Tissue depth confirmed as subcutaneous (above the fascia) — subfascial depth maps to 28041 or 28045
Exact anatomic location specified: which foot, which toe if applicable, and site of incision
Pathology report or documentation that specimen was submitted for histologic analysis
Preoperative diagnosis and clinical indication supporting medical necessity (e.g., pain, functional impairment, growth progression)
Operative note naming the surgical approach, dissection technique, hemostasis method, and closure details — avoid generic 'standard approach' language

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 25 Significant separate E/M 50 Bilateral procedure 51 Multiple procedures 57 Decision for surgery 59 Distinct service 76 Repeat, same physician 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 28039 covers open excision of a subcutaneous (above the fascia) soft tissue mass in the foot or toe when the lesion measures 1.5 cm or greater. The surgeon removes the mass through an incision, achieves hemostasis, and closes the wound in layers. The excised specimen goes to pathology — that's not optional; it's part of the procedure and what justifies the code. Common lesions reported under this code include lipomas, ganglia, and plantar fibromas large enough to meet the size threshold.

Size and tissue depth are the two axes that drive code selection here. If the tumor is subcutaneous but smaller than 1.5 cm, drop to 28043. If it's subfascial (intramuscular) at 1.5 cm or greater, use 28041. If it's subfascial and under 1.5 cm, use 28045. Billing 28039 for a subfascial mass or a mass under the size threshold is a mismatch that auditors catch on operative note review.

28039 carries a 90-day global period. Any E/M visit on the same day as surgery requires modifier 57 if it drove the decision to operate, or modifier 25 if it was a separately identifiable problem. Routine post-op wound checks, suture removal, and dressing changes within the 90-day window are bundled — no separate billing without modifier 24 or 79 depending on whether the service is related or unrelated to the original procedure.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (5.28) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (14.27) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	5.28
Practice expense RVU	8.4
Malpractice RVU	0.59
Total RVU	14.27
Medicare national rate	$476.63
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$476.63
HOPD (APC 5073) Hospital outpatient department	$2,967.63
ASC (PI G2) Ambulatory surgical center (freestanding)	$1,248.36

Common denial reasons

The recurring reasons claims for CPT 28039 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Size not documented or measured below 1.5 cm — payer downcodes to 28043 with recoupment
Tissue depth mismatch: operative note describes subfascial dissection but 28039 (subcutaneous) was billed instead of 28041
No pathology report on file — some payers treat submission of specimen as a coverage requirement, not just a coding detail
Medical necessity not established — documentation shows an asymptomatic, stable lesion with no functional impact or growth
Global period conflict — E/M or minor procedure billed within the 90-day window without the required modifier 24, 25, or 79

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01What separates 28039 from 28043?

Size threshold. Both codes cover subcutaneous foot/toe tumor excision, but 28039 requires the lesion to be 1.5 cm or greater. If the excised mass measures less than 1.5 cm, bill 28043. Document the measured size in the operative note — not just the pre-op estimate from imaging.

02What separates 28039 from 28041?

Tissue depth. 28039 is subcutaneous (above the fascia); 28041 is subfascial (intramuscular), also at 1.5 cm or greater. If your dissection goes through the fascia to reach the mass, 28041 is the correct code regardless of how the lesion presented on physical exam.

03Can 28039 be billed bilaterally?

Yes. If tumors on both feet are excised at the same session, append modifier 50 and bill on a single line. Reimbursement is typically capped at 150% of the single-procedure fee. LT and RT are the alternative if your payer requires separate lines for each side.

04Is a pathology report required to bill 28039?

The CPT code description implies specimen submission, and many payers — particularly MACs — will deny or recoup payment if there's no pathology report in the record. Always send the specimen and document that you did in the operative note.

05How does the 90-day global period affect post-op billing?

All routine post-op care is bundled through day 90: wound checks, suture removal, dressing changes. To bill a separately identifiable E/M for an unrelated problem in that window, use modifier 24. For an unrelated procedure by the same surgeon during the global period, use modifier 79. Modifier 78 covers an unplanned return to the OR for a related complication.

06When is modifier 22 appropriate for 28039?

Use modifier 22 when the procedure required substantially more work than typical — for example, a mass with extensive adhesion to neurovascular structures requiring prolonged, complex dissection. The operative note must detail the specific factors that increased the work. Payers will request documentation before paying the upcharge.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira Scribe

Mira's AI scribe captures the measured lesion size, tissue depth (subcutaneous vs. subfascial), exact anatomic site, dissection technique, and confirmation that the specimen was sent to pathology — the four data points auditors check first on a 28039 claim. Capturing size and depth at dictation prevents the most common denial: a payer downcode to 28043 because the chart never stated the tumor was 1.5 cm or greater.

See how Mira captures CPT 28039 documentation