Surgical removal of a subfascial (e.g., intramuscular) soft tissue tumor of the foot or toe measuring 1.5 cm or greater.

Verified May 8, 2026 · 6 sources ↓

Medicare: $421.19
Work RVU: 6.95
Global, days: 90
Region: Foot & ankle

Drawn from CMSBedrockbillingEmednyFindacodePayerprice

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Tumor depth confirmed as subfascial (intramuscular or deep to fascia) in the operative note — not just implied by imaging
Tumor size documented as 1.5 cm or greater, measured from the surgical specimen or intraoperative findings
Operative note specifies the anatomic location within the foot or toe (e.g., plantar intrinsic musculature, dorsal foot, specific toe)
Pathology specimen submitted and lab report retained in the record to support medical necessity
Pre-operative imaging (MRI or CT preferred) documenting tumor location and depth relative to fascial layers
Indication for surgery documented — symptoms, growth pattern, or concern for malignancy — tying the diagnosis code to the procedure

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 50 Bilateral procedure 51 Multiple procedures 58 Staged or related 59 Distinct service 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 28041 covers excision of a soft tissue tumor located beneath the fascia — intramuscular or otherwise subfascial — in the foot or toe, where the tumor measures at least 1.5 cm. The subfascial depth is the defining distinction from 28039, which covers subcutaneous tumors at the same size threshold. Depth must be documented by operative findings, not inferred from imaging alone.

The 90-day global period applies. That window covers the day-before visit, the procedure itself, and all routine post-op care through day 90. Pathology submission of the excised specimen is standard and separately billable — it falls outside the surgical global package. If the pathology result drives a return to the OR for a related procedure (e.g., wider re-excision of a malignant tumor), use modifier 78. An unrelated foot procedure in the same global window takes modifier 79.

Code selection hinges on two variables: tissue plane (subcutaneous vs. subfascial) and size (less than 1.5 cm vs. 1.5 cm or greater). Radical resection for sarcoma escalates to 28046 or 28047. Billing 28041 when operative notes describe only subcutaneous dissection — without documented fascial penetration — is a common audit trigger.

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 (6.95) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (12.61) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	6.95
Practice expense RVU	4.83
Malpractice RVU	0.83
Total RVU	12.61
Medicare national rate	$421.19
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	$421.19
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 28041 get rejected.

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

Depth not supported: operative note describes subcutaneous dissection only, making 28039 the more accurate code
Size threshold not met: specimen measurement less than 1.5 cm without documentation supporting the larger size threshold
Missing pathology report, leading payers to question whether a true neoplasm was excised versus a non-covered lesion
Laterality modifier absent (LT or RT) when required by payer policy — particularly common with commercial plans
Inadequate medical necessity documentation — diagnosis code does not align with a soft tissue mass requiring subfascial excision

Frequently asked questions

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

01What separates 28041 from 28039?

Tissue plane. Both codes require tumor size of 1.5 cm or greater. 28039 is subcutaneous — above the fascia. 28041 is subfascial — the surgeon penetrated the fascia to reach the tumor. If your operative note doesn't explicitly describe dissecting through or beneath the fascia, 28039 is the defensible code.

02Can I bill pathology separately when I use 28041?

Yes. Pathology (e.g., 88305) is not part of the surgical global package and is billed separately by the pathologist or the facility performing the analysis. The surgeon's 90-day global does not bundle pathology services.

03If MRI shows the mass is intramuscular but the op note is vague about depth, which code applies?

The operative note controls code selection, not imaging. If the op note doesn't document subfascial dissection, you're exposed on audit. Have the surgeon addend the note with specific depth findings before submitting the claim.

04When would 28046 or 28047 apply instead of 28041?

28046 and 28047 are for radical resection — typically sarcoma or aggressive malignancy — where wide margins of surrounding tissue are taken. 28041 is appropriate for excision of a discrete tumor with intent to preserve surrounding tissue. If the pathology comes back sarcoma and a re-excision with wider margins is planned, that return procedure may fall under 28046/28047 with modifier 58 (staged procedure).

05Does the 90-day global period affect billing a same-day E/M?

A same-day decision-for-surgery E/M can be billed with modifier 57 if that visit drove the decision to operate. Routine pre-op visits are bundled. Post-op E/M visits for related issues within the 90-day window are bundled and require modifier 24 (unrelated) or modifier 79 (unrelated procedure) to be separately payable.

06Is 28041 ever billed bilaterally?

Bilateral billing with modifier 50 is technically allowed, but simultaneous bilateral subfascial foot tumor excisions are uncommon and will draw scrutiny. If it's clinically accurate, document each lesion's location, size, and depth separately. Some payers require LT and RT on separate line items rather than modifier 50.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the tumor's anatomic location, fascial depth confirmed intraoperatively, specimen size, and dissection technique from the surgeon's dictation. It flags when the operative narrative omits explicit confirmation of subfascial penetration — the single most common reason an audit downcodes 28041 to 28039.

See how Mira captures CPT 28041 documentation