Primary Care Coding Alert

Question: Our provider removed a vaginal lesion from a patient using a punch technique. His notes indicated that the excised diameter including margins was 0.6 cm and that the excision took longer than usual. Should I use 11421, given the lesion size, location, and removal method, or would 57061 or 57065 be more appropriate?

Codify Subscriber

Answer: There are a number of issues that you need to address in an excision such as this. First, 11421 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm) notes that the code can be used for excising benign genital lesions, and the size of the lesion removed matches the code descriptor. However, the 11400-11446 codes are generally used for removal of such benign lesions as “neoplasm, cicatricial, fibrous, inflammatory, congenital, [or] cystic lesions” according to CPT®.

Additionally, the 11400-11446 codes are integumentary codes and should only be used for excision of skin lesions, not for excision of lesions on internal structures of the genitourinary system.

This suggests that you should look toward a more site-specific code. Using either 57061 (Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) or 57065 ( … extensive …) implies the physician removed the lesion through destruction rather than excision. Even though the destruction methods described by the codes do not include using a punch technique, and the work described is close to the work indicated by 11421, the location of the lesion would override your choice of 11421.

Your choice of either 57061 or 57065 will then depend on the physician’s clinical judgement. Factors such as the number and size of lesions removed, how high they sat above the skin surface, and how much time the provider needs to remove them would all come into play into your code choice. Your provider’s notes point to 57065 given the size of the lesion and that your provider noted the excision took longer than usual. However, as always, you should check the documentation and go back to your physician to confirm these details before making the decision to code 57065.

Coding alert: If the physician actually excised the lesion via punch technique and the lesion in question was a cyst or tumor, then you should look to code 57135 (Excision of vaginal cyst or tumor).