Ob-Gyn Coding Alert

Question: What should I report for a bilateral labioplasty?

Texas Subscriber

Answer: Before you can find the correct code for a bilateral labioplasty, you have to read your ob-gyns description of the procedure.

For instance, did he remove excess tissue? If so, you should report 15839 (Excision, excessive skin and subcutaneous tissue [includes lipectomy]; other area).Did he remove labial adhesions? If so, you should report 56441 (Lysis of labial adhesions).

As for a bilateral labioplasty, you will not have the option of including modifier 50 (Bilateral procedure) because neither one of the codes mentioned above allow it under Medicare rules. Remember, these codes do imply that the procedure is unilateral, but are described in such a way that implies all tissue removed would be included, so you cannot report two procedures.