Ob-Gyn Coding Alert

Question: My ob-gyn documented the following:

Attention was drawn to vagina. The areas of vestibulitis were recognized. Skin was infiltrated with 1/4% Marcaine with epi around total lesion. The lesions were incised around the area of inflammation with a scalpel and the skin removed with usual technique. The vaginal tissue was undermined. Bovie cautery was used to obtain hemostasis. The vaginal tissue was brought down to the level of the incision of the vulva. The vaginal tissue was then reattached to the vulvar tissue plain using vertical mattress stitches of 3-0 Vicryl. After noting adequate closure and hemostasis, all instruments were removed. Premarin vaginal cream was placed in the vagina to aide in healing. Path report: squamous mucosal lined fibrous soft tissue with mild chronic inflammation. No malignancy or dysplasia.

It doesn’t look to me like it meets the requirement for a vulvectomy. How should I report this?

Tennessee Subscriber

Answer: You should report skinning vulvectomy using the vulvectomy codes, but in this case, it appears to be a partial removal. A simple vulvectomy is the removal of skin and superficial subcutaneous tissue, which was done, so your code would be 56620 (Vulvectomy simple; partial). He then covered the area removed with vaginal tissue. Many times, the ob-gyn will take a graft from the thigh to cover the area, but this was not done in this case.