Ob-Gyn Coding Alert

Question: My ob-gyn documented this:

Dx: Multiple Vulvar Lesions: Pt had vulvar bx that showed polypoid tissue, decision now made for excision. Procedure Note: Pt taken to OR and wide local excision @ 12 & 4 o’clock made encompassing the largest of the coliform lesions, following excision laser set at 4 watts and cauterization and vaporization of genital lesions were done, some areas required 6 watts of energy, then inclusion cysts along the vulva were incised sebaceous material removed from cyst, cyst walls were then vaporized with laser for hemostasis. Wide local excisions were then closed with simple interrupted sutures.

The path report listed:

A. Vulvar at 4’oclock measurement 0.7x0.7x0.3cm
B. Vulvar at 12’oclock measurements 1.0x0.6x0.3cm

Would CPT^® codes 57513; 11420; and 56441 be appropriate for this surgery?

Iowa Subscriber

Answer: Your ob-gyn included no description of cervical cautery (57513, Cautery of cervix; laser ablation), but for the two excised lesions, you code each separately based on its greatest diameter. Therefore, you have 11421 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm) X 2, and for the destruction of the other lesions, it would be maybe 56515 (Destruction of lesion[s], vulva; extensive [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery]). Your documentation does not indicate how many.

There is no description of the work for labial adhesions, so you should not report 56441 (Lysis of labial adhesions) unless you have it.