Ob-Gyn Coding Alert

Find out what a “radical vulvectomy” really means.

If you incorrectly report an integumentary code instead of a vulvectomy code, you could be depriving your practice a lot of money. Choosing a vulvectomy versus a vulvar lesion excision code depends entirely on your ob-gyn’s documentation. Look for:

• Type of lesion
• Lesions size (plus margin)
• Layer closure.

Check your relative value units (RVUs). All vulvectomies have more RVUs than lesion excisions because vulvectomies involve much more work. For instance, 56620 (Vulvectomy simple; partial) pays much more than the most expensive of malignant lesion excision codes (11620-11626, Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia....)

Choose Vulvectomy for Non-Discrete, Large Tissue Areas

If the lesion is not discrete and involves large areas of tissue (such as extensive dysplasia), your ob-gyn will perform a vulvectomy:

• 56620 — Vulvectomy simple; partial
• 56625 — ... complete
• 56630 — Vulvectomy, radical, partial;
• 56631 — ... with unilateral inguinofemoral lymphadenectomy
• 56632 — ... with bilateral inguinofemoral lymphadenectomy
• 56633 — Vulvectomy, radical, complete;
• 56634 — ... with unilateral inguinofemoral lymphadenectomy
• 56637 — ... with bilateral inguinofemoral lymphadenectomy
• 56640 — Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy
  

Definition: CPT® defines a simple vulvectomy as the removal of skin and superficial subcutaneous tissue. The classic definition of a simple vulvectomy is the removal of benign disease by the superficial removal of vulvar structures (such as labia minora, labia majora, clitoris, etc.), including the skin, mucous membrane, and any superficial fat and connective tissue.

Key terms: When reporting a vulvectomy, you should watch for key terms. For instance, a radical vulvectomy, includes excising most or all of the skin and deep subcutaneous tissue. A partial vulvectomy means the physician removes less than 80 percent of the vulva (for example, the left labia).

Focus on Lesion Size for Integumentary Codes

For lesions that are discrete and localized, however, you will look at the “Integumentary System” chapter of your CPT® book — and not the “Female Genital System” chapter.

Benign: You should report 11420-11426 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia ...) for the excision of discrete vulvar lesions, which require removal of only narrow surgical margins. What code you report depends on the lesions size — plus the margin removed.

Malignant lesions usually involve wide excisions. For this, you should report 11620-11626 (Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia ...). Again, what code you report depends on the lesion’s size plus any margins. In some cases, when the ob-gyn cannot confirm a lesion as benign, but the ob-gyn still takes wide margins while removing the lesion, you still may report the malignant excision codes, according to CPT® guidelines.

You May Be Able to Report Layer Closure

If your ob-gyn has to do more than a simple closure of the remaining tissues (an intermediate or complex repair), you should add another code. You may report 12041-12047 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia ...) or 13131-13133 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet ....).

Watch out: The size of the lesion and that of the repair must match your ob-gyns documentation. Also, if a complex repair is 1.0 cm or less, CPT® instructs you to report the repair as intermediate, not complex.

Don’t Overlook Your Diagnosis Coding Options

Along with scrutinizing your ob-gyns documentation for lesion size, lesion margin, and layer closure, you should take note of the patient’s diagnosis. For instance, an infection (such as the human papilloma virus [HPV]) or irritant may cause vulva dysplasia. But it is the vulvar dyplasia that would be coded in support of the lesion removal rather than the cause of the condition. ICD-9 has the following codes to report this:

• 624.01 — Vulvar intraepithelial neoplasia I (VIN I)
• 624.02 — Vulvar intraepithelial neoplasia II (VINII)
• 233.32 — Carcinoma in situ, vulva.
  

Did you know? If the pathology report returns with indications of dysplasia, the neoplasm is in transition from being benign to becoming malignant. If the process continues and the mass is left untreated, the neoplasm could eventually become invasively malignant.

ICD-10: When your diagnosis system changes, the codes above will become:

• N90.0 — Mild vulvar dysplasia
• N90.1 — Moderate vulvar dysplasia
• D07.1 — Carcinoma in situ of vulva.