Oncology & Hematology Coding Alert

Key: Look for lesion type, size along with margins excised, and any closure work.

When reporting vulvar lesions, you need to be very careful to determine whether your provider performed a vulvectomy or vulvar lesion excision. Not doing so could cost you deserved income.

RVU difference: All vulvectomies (simple, partial, and radical) have more RVUs than lesion excisions because vulvectomies involve much more work. For instance, 56620 (Vulvectomy simple; partial) has 15.25 RVUs and pays approximately $518.85, whereas 11620 in the malignant lesion excision code series (11620-11626, Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia....) pays $123.50.

Choose Vulvectomy for Non-Discrete, Large Tissue Areas

If the lesion is not discrete and involves large areas of tissue (such as extensive dysplasia), your physician will perform a vulvectomy:

• 56620 — Vulvectomy simple; partial
• 56625 — ... complete
• 56630 — Vulvectomy, radical, partial;
• 56631 — ... with unilateral inguinofemoral lymphadenectomy
• 56632 — ... with bilateral inguinofemoral lymphadenectomy
• 56633 — Vulvectomy, radical, complete;
• 56634 — ... with unilateral inguinofemoral lymphadenectomy
• 56637 — ... with bilateral inguinofemoral lymphadenectomy
• 56640 — Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy

Definition: CPT® defines a simple vulvectomy as the removal of skin and superficial subcutaneous tissue. The classic definition of a simple vulvectomy is the removal of benign disease by the superficial removal of vulvar structures (such as labia minora, labia majora, clitoris, etc.), including the skin, mucous membrane, and any superficial fat and connective tissue.

Key terms: When reporting a vulvectomy, you should watch for key terms. For instance, a radical vulvectomy, includes excising most or all of the skin and deep subcutaneous tissue. A partial vulvectomy means the physician removes less than 80 percent of the vulva (for example, the left labia).

Example: You may read that in a patient diagnosed with multilocal invasive vulvar cancer, your oncologist made an elliptical lateral vulvar incision, commencing on the mons pubis anteriorly and extended posteriorly along the labiocrural folds to the perianal area. You may read that the incision was carried down to the fascia lata. Further in the operative note, you will confirm that the medial incision was placed such as to facilitate tumor excision with margins of at least 1 cm. Removal of the entire vulva, lymph node dissection, and closure of large defect (reconstruction using flaps, if too extensive) help you to confirm a radical vulvectomy.

Focus on Lesion Size for Integumentary Codes

For lesions that are discrete and localized, however, you will look at the "Integumentary System" chapter of your CPT® book — and not the "Female Genital System" chapter.

Benign: You should report 11420-11426 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia ...) for the excision of discrete vulvar lesions, which require removal of only narrow surgical margins. What code you report depends on the lesions size — plus the margin removed.

Malignant lesions usually involve wide excisions. For this, you should report 11620-11626 (Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia ...). Again, what code you report depends on the lesion’s size plus any margins. In some cases, when the clinician cannot confirm a lesion as benign, but the physician still takes wide margins while removing the lesion, you still may report the malignant excision codes, according to CPT® guidelines.

You May Be Able to Report Layer Closure

If your clinician has to do more than a simple closure of the remaining tissues (an intermediate or complex repair), you should add another code. You may report 12041-12047 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia ...) or 13131-13133 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet ....).

Watch out: The size of the lesion and that of the repair must match your physician’s documentation. Also, if a complex repair is 1.0 cm or less, CPT® instructs you to report the repair as intermediate, not complex.

Example: You may read that in a patient with a large vulval defect or with prior surgery or radiation treatment, your oncologist excised wider margins and repaired the large defect of more than 6 cm with a rhomboid flap. In this case, you confirm the complex nature of repair and report it with 13132 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm).

Don’t Overlook Your Diagnosis Coding Options

Along with scrutinizing your clinician’s documentation for lesion size, lesion margin, and layer closure, you should take note of the patient’s diagnosis. For instance, an infection (such as the human papilloma virus [HPV]) or irritant may cause vulva dysplasia. But it is the vulvar dyplasia that would be coded in support of the lesion removal rather than the cause of the condition. ICD-9 has the following codes to report this:

• 624.01 — Vulvar intraepithelial neoplasia I (VIN I)
• 624.02 — Vulvar intraepithelial neoplasia II (VIN II)
• 233.32 — Carcinoma in situ, vulva.

Did you know? If the pathology report returns with indications of dysplasia, the neoplasm is in transition from being benign to becoming malignant. If the process continues and the mass is left untreated, the neoplasm could eventually become invasively malignant.

ICD-10: When your diagnosis system changes, the codes above will become:

• N90.0 — Mild vulvar dysplasia
• N90.1 — Moderate vulvar dysplasia
• D07.1 — Carcinoma in situ of vulva.
• Example: Your oncologist may document a stage 0 vulvar neoplasm when the pathology report states that the cancerous cells were limited to the surface of the vulvar skin and were not located beyond the skin. In this case, you report ICD-9 code 233.32 and ICD-10 code D07.1.