Ob-Gyn Coding Alert
Go In-Depth With This Vulvar Ulcer Scenario
Question: I have been going in circles with this procedure. Our provider performed a right vulva resection for a non-healing ulcer of the vulva. The body of the report reads: “The labia was marked with a pen so that the entire non-healing ulcer could be resected. A large elliptical incision involving the entire ulcer as well as lateral labial tissue was created with the scalpel. The skin was elevated, and the fatty tissue wedged out so that the skin could be brought together without tension. Bleeding controlled ... deep tissue was re-approximated with 3-0 Vicryl sutures, one from the top and the other from the inferior of the incision.” I thought a code from the 1142- section would be best but no measurements were listed in the report. CPT® 56620 comes up quite a bit in researching this procedure, but it wasn’t a “precancerous” or “cancerous” lesion. I was thinking I would request excised measurements from the provider in order to use a code from the 1142- section, but I’m not so sure. What should I do? Texas Subscriber Answer: It seems like your provider performed a wide local excision. Depending on the reason for surgery, and the amount of tissue removed, you may be led to 56620 (Vulvectomy simple; partial) versus 1142- (Excision, benign lesion including margins …). In your example, you should choose from 1142- as the provider removed a discrete area which was not precancerous or cancerous. You might consider 56620 if the ulcer plus margins was so large that a significant portion of vulva was excised. You should query your clinician to amend the record to include the size of the excision (remember, code size of the excision, not just size of the lesion/ulcer.) A far less ideal alternative would be to check the size on the pathology report. As specimens sometimes shrink after excision, this is definitely only a last resort. You may also provide educational guidance to your provider about documentation of the size of excision for the future. Keep in mind: A vulvar ulcer is always benign.
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Go In-Depth With This Vulvar Ulcer Scenario
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