# CPT Coding for GYN/Onc - Vulvectomy/WLE/Complex Repair



## sscott@hogonc.com (Nov 19, 2013)

I work at an oncology clinic. We recently added a gynecologic oncologist who does GYN surgeries.  The patient has VIN III 233.32. The surgeon did a left vulvectomy 56620, right vulvar wide local excision 11424, and a complex wound closure on the left 13132.  Medicare is bundling the 56620 and the 13132 and will not pay for the WLE with the diagnosis we reported (233.32). The LCD does not list a diagnosis that we can use.  I am curious if anyone has any tips on this or if the 56620 partial vulvectomy is all we can bill for this.  Thanks!


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## OCD_coder (Nov 19, 2013)

Without seeing the actual Op Report it is hard to give a completely accurate answer to the question.  First, the closure (13132) is inclusive when a surgical procedure (56620) is performed.  The surgeon is in the same body area.  

I would have to review the 11424 documentation, even though it is possibly a difference lesion and see if it would possibly qualify for the complete vulvectomy (56625) and also look at the pathology report for additional information.

As a fellow surgical coder with years of GYN-ONC surgical experience, the vulva is a single body area as is the integumentary system and you have take out the laterality idea (LT and RT) when selecting codes.


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## sscott@hogonc.com (Nov 21, 2013)

Thanks for your input, OCD_Coder! I am going to go ahead and post the OP and Path reports to see if it clarifies some of the questions you pointed out. 

*OPERATIVE REPORT*

Preop/Postop Diagnosis: Severe Vulvar Dysplasia

Procedure: 
1. Left vulvectomy 
2. Left complex multilayer closure
3. Right wide local excision measuring 2 x 2 cm. 

Findings: 
The patient had a very large left vulvar lesion, and it did encroach on the clitoris.  We closed as we could on that side.  The right lesion was not very large.  It was more of an ulcerative-type lesion consistent with vulvar dystrophies.   We removed it in its entirety with a 1 cm margin.  The entire resection was 3 x 3 cm. 

Description of Procedure: 
After informed consent was obtained, the patient was taken to the operating room and general endotracheal anesthesia was obtained without complications.  She was sterilized, prepped, and draped in a normal standard fashion.  Time-out was performed.  I then washed the Betadine free, isolated the lesions.  I undermined them with local.  I worked on teh left side, performed left vulvectomy.  The margins were over 1 cm circumferentially with the exception of the clitoral hood, which I saved and did not want to resect to the clitoris for vulvar dysplasia.  I then undermined it and marked it at 12 o'clock.  I then stopped teh bleeding with Bovie and suture.  I then closed the inferior margin with multiple Vicryl followed by subcuticular stitch followed by multiple horizontal and vertical mattresses.  I then turned my attention ot the right, where I isolated the lesion, grasped it with Allis, and then undermined it.  I then performed a 1 cm wide local excision on this area and closed this primarily with multiple interrupted, irrigated, and noted it to be hemostatic.  I injected local again in the pudendal nerves bilaterally and then placed Dermabond across the incision sites.  She was then taken out of dorsal lithotomy, turned to dorsal supine, extubated, and taken to the recovery room with stable vital signs. All counts were correct at this time.  There were no intraoperative complications noted. 

*PATHOLOGY*

History/Clinical Data:
History of high grade vulvar dysplasia.

Preop Diagnosis: 
Left vulvar mass. 

Specimen(s) Submitted: 
A. Left vulvectomy, stitch at 12 o'clock
B. Right wide local excision vulva

Gross Description: 
A. Received in formalin labeled with patient's name and "left vulvectomy--stitch at 12 o'clock" is a 5 x 2.5 x 0.5 cm left vulvectomy that has a pale white to pink area of discoloration that is 3.2 x 1.8 cm.  The specimen is marked at the 12 o'clock position.  The 12-3-6 o'clock margin is inked blue, the 6-9-12 o'clock margin is inked green, and the deep margin is inked black.  The specimen is entirely submitted moving from 12 to 6 o'clock cassettes A1-A6 with the 12 and 6 o'clock border sectioned perpendicular to the long axis (please see diagram on requisition sheet).  

B. Received in formalin labeled with the patient's name and "right wide local excision of vulva" is a 1.5 x 1 x 0.4 cm pink-tan soft wrinkled segment of skin.  The unoriented specimen is inked black on the resected margin and the specimen is entirely submitted from one end to the opposite end in cassettes B1-B3.   

Final Diagnosis:
A. Left Vulvectomy
     Moderate to severe squamous dysplasia (VIN II-III) which extends to teh peripheral margin in teh 9-12 and 12-3 o'clock regions.  No invasive cancer identified. 

B. Right Wide Local Excision Vulva
     Benign skin, no dysplasia nor malignancy identified. 

Any input will be greatly appreciated!


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