Ob-Gyn Coding Alert

Reviewed on May 20, 2015

Question: What is the correct code for wide excision of vulva? Is that a vulvectomy? The patient is status post overt carcinoma treated with wide excision. Colposcopy exam shows some white epithelium in the posterior fourchette and inner aspect of the right labia majora. Should I use 56605?

 Wisconsin Subscriber

 Answer: If the wide excision involved the removal of skin and superficial subcutaneous tissue, then your ob-gyn performed a vulvectomy. You would therefore use code 56620 (Vulvectomy, simple; partial). According to the Coder's Desk Reference, you should report 56620 when "the physician removes part of the vulva to treat premalignant or malignant lesions."

 If the ob-gyn took a sample of the white areas, you should report the vulva biopsy code 56605 (Biopsy of vulva or perineum [separate procedure]; one lesion). Vulvar biopsy is an office-based procedure during which the physician takes a sample of an abnormal mole, lesion or other dermatosa that does not respond to topical or other conventional treatments. Following topical anesthesia, the physician takes the biopsy sample via shaving the lesion, excising or puncturing the cyst or lesion and extracting the sample.

 However, because you mentioned that your ob-gyn performed a colposcopy at the time, you should most likely report 56821 (Colposcopy of the vulva; with biopsy[s]). This code includes examining the vulva with the colposcope and then performing a biopsy with or without the instrument's aid.