Genital warts, or lesions, is a common sexually transmitted disease (STD) and one that gynecologists treat through routine methods of removal. But when lesions are present in several different sites of the female genital organs, including the vulva, vagina and cervix, apply the coding rules for lesion removal from multiple sites to optimize reimbursement. Also, keep in mind the difference between destruction and excision when searching for the correct code.
Genital warts and other gynecological lesions can be removed one of two ways through excision or destruction. When a lesion is excised, it is cut away from the surrounding tissue and sometimes biopsied. Destruction involves breaking down the lesion by any number of methods, including chemical and laser treatment, electro- and cryosurgery, during which the lesion is frozen off using liquid nitrogen or carbon dioxide. The tissue of the lesion is destroyed, and no biopsy is conducted. With routine and recurrent vaginal warts, destruction is the most common method of removal.
There are several coding options for the destruction of lesions of the female genital areas. Some coders may be tempted to go directly to the destruction codes (17000-17004), but a number of factors go into determining which code to use the location of the lesion(s), the number of lesions and the destruction method. The physician’s operative note should clearly identify whether the lesions were on the vagina, vulva, other areas like the cervix or anus or in a number of areas simultaneously. The codes for destruction of lesions are:
46900 destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical
46910 electrodesiccation
46916 cryosurgery
46917 laser surgery
46922 surgical incision
46924 destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive, (Update: (eg. Laser surgery, electrosurgery, cryosurgery, chemosurgery)
56501 destruction of lesion(s), vulva; simple, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
56515 extensive, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
57061 destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
57065 ... extensive, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
If multiple warts were destroyed from both the vulva and vagina, the destruction would be coded as 56515, 57065-51, (multiple procedures). However, if the location of the warts is other than the vulva or vagina, and they are located on the skin and not the cervix, the inner thigh, or buttocks area for instance, choose from one of the following codes:
17000 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion
+17003 ... second through 14 lesions, each (list separately in addition to code for first lesion)
17004 ... 15 or more lesions
Note: Code 17004 is modifier -51 exempt but cannot be reported in conjunction with codes 17000 and 17003.
Per CPT®’s definition, destruction methods include electrosurgery, cryosurgery, laser and chemical treatment. Lesions include condylomata, papillomata ... or other benign, premalignant, or malignant lesions. Jennie Campbell, CPC, CCS-P, manager at Pershing, Yoakley & Associates, P.C., a Knoxville, Tenn.-based CPA firm that offers consulting services for hospitals and physicians, explains: Destruction is not the same thing as excision, but destruction is also via chemical methods, therefore 56501 would be the correct code for genital warts on the vulva treated with TCA. The difference between simple and extensive comes down to the number and size of the lesions/warts, but CPT® does not define “extensive.” As a general rule of thumb, multiple warts or ones that are large and significantly raised off the skin surface and require more time and/or chemicals to remove, may be considered extensive destruction. The ACOG (American Congress of Gynecologists and Obstetricians) coding manual states that this procedure (56501) includes destruction of simple or single lesion(s), Campbell says. In my opinion, if a patient has more than a couple of vulvar-area warts, use of 56515 is warranted.
It is important not to confuse the chemical destruction of vaginal warts with the chemical irrigation of the same area. Katie McClure, RHIA, surgical coder with Southeastern Gynecologic Oncology, a six-physician specialty practice in Atlanta, clarifies potential confusion. I’m familiar with coders who use 57150 (irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease) for destruction of vaginal warts, McClure says. Although this might seem like the right code for chemical application to treat venereal warts, it does not match the diagnosis. She explains that venereal warts or condyloma are a viral manifestation (see Diagnostic Factors, below) and 57150 is reported for the treatment of bacterial, parasitic or fungoid disease. Also, McClure says, 57150 involves the physician using a catheter or similar tube high into the vaginal canal to flush the canal with a medicated solution not the direct application to the affected area as with a chemical destruction.
Occasionally, surgery is needed to remove large warts that have not responded to other treatment. For the excision of lesions of the female genital area, several codes are possible, depending on the location of the lesion and whether the physician has cause to order a biopsy of the excised tissue:
11420 excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia;excised diameter 0.5 cm or less
For excision of larger benign lesions, use 11421-11426, depending on the size.
57100 biopsy of vaginal mucosa; simple (separate procedure)
57105 ... extensive, requiring suture (including cysts)
57500 biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure).
Diagnostic Factors
As with other STDs like genital herpes, the patient still carries the human papillomavirus infection virus (HPV) even when no symptoms are visible. But vaginal or genital warts can be diagnosed in a patient only when symptoms are present. A physician can usually diagnose warts by visual examination, and a Pap smear can confirm the diagnosis. A colposcopy can also detect the presence of warts or condylomata in the interior of the vagina. In some cases, it is necessary to do a biopsy of cervical tissue.
For diagnostic coding, the following options exist:
078.10 viral warts, unspecified 078.11 condyloma acuminatum (includes condyloma and genital warts not otherwise specified [NOS])
078.19 other specified viral warts
091.3 secondary syphilis of skin or mucous membranes (includes secondary syphilis of anus and vulva and condyloma latum).
In addition, the human papillomavirus causing the warts needs to be identified as the viral agent and coded 079.4 (human papillomavirus in conditions classified elsewhere and of unspecified site). This serves as the secondary diagnosis to the code for the lesion.
When your diagnosis system changes to ICD-10, you will report these codes instead:
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078.10 = B07.9 Viral wart, unspecified
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078.11 = A63.0 Anogenital (venereal) warts
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078.19 = B07.8 Other viral warts
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091.3 = A51.31 Condyloma latum or A51.39 Other secondary syphilis of skin
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079.4 = B97.7 Papillomavirus as the cause of diseases classified elsewhere
Complete Coding
Remember that when coding for in-office removal of vaginal warts, physicians can charge both the code for the destruction or excision of the warts, and an evaluation and management (E/M) visit for a new or returning patient (99201-99215).
The E/M code is appended with modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to indicate that the E/M service was separate and significant from the wart removal. Campbell points out that the exception to this rule occurs when, instead of destroying the warts in-office, the physician gives the patient a prescription for a topical medication that she applies herself at home.
