Ob-Gyn Coding Alert

Incorrectly reporting the wrong code could cost as much as $400 a claim.

When your ob-gyn treats a patient for a vulvar lesion and the claim lands on your desk, it’s up to you to decide between an integumentary code versus a vulvectomy — and if you choose wrong, you could cost your practice money that it ethically deserves. So what should you do?

Bust these four prevalent myths that could lead to inaccurate or incomplete claims. You’ll need to dig into your ob-gyn’s documentation and look for the type of lesion, the lesion size (plus margin), and the layer closure.

Why this is so important: 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) has 14.92 RVUs (or $535.46, based on the 2017 conversion factor of 35.8887) —much more than the most expensive of malignant lesion excision codes (11620-11626, Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia...). The most expensive code 11626 (… excised diameter over 4.0 cm) has 11.61 nonfacility RVUs.

Biggest impact: This means if you reported the least expensive code (11620, … excised diameter of 0.5cm or less), which has 3.47 facility RVUs or $124.53, when you could have reported 56620, you could be missing out on $410.93 of ethical reimbursement.

Myth #1: No CPT^® Code Exists for Non-Discrete, Large Tissue Areas

Truth: According to Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wis., 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 or premalignant disease by the superficial removal of vulvar structures. “It is the removal of the labia minora, labia majora, clitoris, etc.,” says Jill Richardson, coder at Gynecologic Surgeons and Obstetricians in Lincoln, Neb. It also includes the skin, mucous membrane, and any superficial fat and connective tissue.

Vulvectomies can be more than simple. 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), Rasmussen says.

Myth #2: For Lesions Discrete/Localized, Look to “Female Genital System” Chapter 

Truth: For lesions that are discrete and localized, 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, Rasmussen says.

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.

Myth #3: You Will Not Be Able to Report Layer Closure

Truth: 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 when reporting the integumentary codes. 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, Rasmussen says.

Myth #4: Your Diagnosis Coding Options Do Not Matter

Truth: Along with scrutinizing your ob-gyn’s 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 dysplasia that would be coded in support of the lesion removal rather than the cause of the condition. ICD-10 has the following codes to report this:

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