Ob-Gyn Coding Alert

Contemplating an integumentary code? Avoid making this $139 mistake.

When you’re deciding whether to report a vulvectomy code versus a vulvar lesion excision code, you need to stop and think about three aspects in the report:

• The type of lesion
• Lesion size (plus margin), and
• The layer closure.

Why it matters: Check your relative value units (RVUs). All vulvectomies have more RVUs than lesion excisions because vulvectomies involve much more work, says Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, N.M. For instance, 56620 (Vulvectomy simple; partial) pays $559 while the most expensive of malignant lesion excision codes (11620-11626, Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia …) carries a $420 non-facility allowable. That’s a difference of $139.

Non-Discrete, Large Tissue Areas Mean Vulvectomy Code

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).

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, Witt says.

Key terms: When reporting a vulvectomy, you should watch for key terms. For instance, a complete radical vulvectomy, includes excising the entire vulva and deep tissues, including the clitoris. A partial vulvectomy means the physician removes less than 80 percent of the vulva (for example, the left labia), but it can be a partial radical procedure, which means only part of the vulva is removed with the deep tissues.

Lesion Size Means the Most 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 lesion’s size — plus the margin removed.

Malignant: 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.

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 (Layer closure of 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-gyn’s documentation. Also, if a complex repair is 1.0 cm or less, CPT^® instructs you to report the repair as intermediate, not complex, Witt says.

Don’t Overlook Dx

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 dystrophy.

ICD-10-CM offers the following codes:

• 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 malignant, Witt points out.