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Wiki EXCISION OF VULVAR LESIONS

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TanBro

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Procedure: Wide local excision of left vulvar lesion and excision of 2 right labial lesions
Diagnosis for path report: severe vulvar dysplasia Cin 3 on all 3 lesions

Acetic acid was applied to the vulvar area and lesions were identified. She had a 2 mm lesion on the upper right labia that was excised and the base cauterized with a single suture of 3-0 vicryl placed. She then had a 3-4 mm lesion in the right labia majora that was excised with the base cauterized and two 3-0 vicryl placed. On the left labia she had a 2x3 cm lesion that was excised and marked at 12 o'clock position. The base was cauterized. Interrupted 3-0 vicryl sutures were used to reapproximate the subcutaneous tissue and the skin was closed with a vertical mattress suture or 3-0 vicryl in an interrupted fashion. The vulva was cleaned and a triple antibiotic ointment applied.

I'm thinking it would be 11620, 11620, and 11623 with 12042 closures but not 100% sure. Can someone help me out please?
 
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The documentation is rather poor, in my opinion, in that is does not describe the excision beyond just stating that it was done. That aside, I agree with your three excision codes. 12042, however, is not supported because the length of that closure is not documented. Generally speaking, an auditor would not allow you to assume that the size of the lesion and the length of the closure are the same.
 
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Another vote for poor documentation!
However, this actually seems more like a simple partial vulvectomy to me. If you have access to the ob/gyn coding alerts: https://www.aapc.com/codes/coding-n...u-be-the-coder-wide-excision-of-vulva-article
Basic idea - WLE of lesion and subq tissue for malignant or pre-malignant lesions would be coded as vulvectomy. Excising a defined lesion for benign conditions would be 11420-11426. I would only use 1162___ if it was skin only (not subq) or one defined malignant lesion, not wide local excision.
It is a gray area, but the Coding Alert does guide you to 56620 vs 1162#.
FYI - some recommendations to improve documentation. I would use this note as an education tool to my provider.
Size - exact measurements (to mm) of excision size (lesion PLUS diameter) are key. So 3cmx4cm lesion might have actually been a 3.8cmx5.2cm excision.
Depth of excision - while I am sort of inferring here subq tissue was taken since layer closure was done, it does not explicitly state so.
Closure - length of closure (to mm) in addition to the already documented type of closure.
 
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Very interesting topic and challenging. Since I am new to OBGYN, I’m trying to get a good understanding in choosing CPT from integumentary section versus Vulvectomy. I appreciate sharing your expertise. My thoughts are: The article says a wide excision of vulva and they recommended 56620. Unfortunately, they did not specify what percentage of Vulva was excised. For 56620 it has to be less than 80% excised vulva. Maybe that was the case in the article.
In our example above, small lesions were excised and I thought to go with 116xx code plus repair.
I also would like to add that 116XX codes describe excision of full thickness, which is dermis, epidermis and Subcutaneous Tissue. So it is confusing. And I’m glad Christine said it’s a grey area. I am absorbing all available knowledge. Thank you for sharing your expertise and a good article.
 
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csperoni said:
Another vote for poor documentation!
However, this actually seems more like a simple partial vulvectomy to me. If you have access to the ob/gyn coding alerts: https://www.aapc.com/codes/coding-n...u-be-the-coder-wide-excision-of-vulva-article
Basic idea - WLE of lesion and subq tissue for malignant or pre-malignant lesions would be coded as vulvectomy. Excising a defined lesion for benign conditions would be 11420-11426. I would only use 1162___ if it was skin only (not subq) or one defined malignant lesion, not wide local excision.
It is a gray area, but the Coding Alert does guide you to 56620 vs 1162#.
FYI - some recommendations to improve documentation. I would use this note as an education tool to my provider.
Size - exact measurements (to mm) of excision size (lesion PLUS diameter) are key. So 3cmx4cm lesion might have actually been a 3.8cmx5.2cm excision.
Depth of excision - while I am sort of inferring here subq tissue was taken since layer closure was done, it does not explicitly state so.
Closure - length of closure (to mm) in addition to the already documented type of closure.
Click to expand...
Thank you so much!! Great information, I will definitely be talking to my providers about documentation lol. I originally thought the vulvectomy code, but my providers don't like using it. Obviously in this case I think that is what it should be with this article.
 
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thomas7331 said:
The documentation is rather poor, in my opinion, in that is does not describe the excision beyond just stating that it was done. That aside, I agree with your three excision codes. 12042, however, is not supported because the length of that closure is not documented. Generally speaking, an auditor would not allow you to assume that the size of the lesion and the length of the closure are the same.
Click to expand...
Thank you so much for your reply. Yes, I will definitely be talking to my providers about documentation.
 
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csperoni said:
Another vote for poor documentation!
However, this actually seems more like a simple partial vulvectomy to me. If you have access to the ob/gyn coding alerts: https://www.aapc.com/codes/coding-n...u-be-the-coder-wide-excision-of-vulva-article
Basic idea - WLE of lesion and subq tissue for malignant or pre-malignant lesions would be coded as vulvectomy. Excising a defined lesion for benign conditions would be 11420-11426. I would only use 1162___ if it was skin only (not subq) or one defined malignant lesion, not wide local excision.
It is a gray area, but the Coding Alert does guide you to 56620 vs 1162#.
FYI - some recommendations to improve documentation. I would use this note as an education tool to my provider.
Size - exact measurements (to mm) of excision size (lesion PLUS diameter) are key. So 3cmx4cm lesion might have actually been a 3.8cmx5.2cm excision.
Depth of excision - while I am sort of inferring here subq tissue was taken since layer closure was done, it does not explicitly state so.
Closure - length of closure (to mm) in addition to the already documented type of closure.
Click to expand...
One more question, would the 2 additional vulvar lesions be included in the vulvectomy code? I'm thinking it would all be in the one code 56620.
 
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tanyabrown said:
One more question, would the 2 additional vulvar lesions be included in the vulvectomy code? I'm thinking it would all be in the one code 56620.
Click to expand...
Yes, if you are coding for simple partial vulvectomy, all excisions are included.

Regarding @natashalage comment for percentage of vulva removed for partial vs complete. I have interpreted complete must be documented as 80% or more. No statement of complete or >80% is partial. If description of partial vulvectomy was 20-79%, then you would need to know the percentage for all cases. But "less than 80%" could be even 1%.
Like for hospital discharge codes 99238 vs 99239. If it's not documented as 30 minutes or more, then it's simply less than 30 minutes.
 
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nielynco said:
Just my two cents. When discrete lesions are removed, use the integumentary codes, if a section of the vulva is removed which contains multiple lesions use the vulvectomy code.
Click to expand...
My two cents without that Ob/Gyn coding alert would be exactly the same. However, when there is reputable source specifying to bill with a higher valued code, I will absolutely take advantage of that. 🤑
My docs are typically removing multiple and/or large lesions or areas when a malignancy or pre-malignancy, so 99% of the time, our combined four cents agree with partial vulvectomy. The remaining occasional situations, I make a judgement call. If it's one small pre-malignant lesion, I lean to integumentary codes. If it's multiple or a large lesion, I lean toward vulvectomy. I don't have any exact formula/cutoff size for this.
 
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Hi all,
I am studying for my COBGC and the 2022 study guide addresses this in the following manner. " Do not report vulvectomy for wide excision of a benign or malignant lesion. For these procedures, refer to the appropriate codes from the integumentary portion of CPT (11400-11646) Hope this helps.
 
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hey everyone,

I'm not positive on lesion size for correct code for range 11400-11646. if anyone can help me. lesion is 2x3x2. are the 2's the margins and the 3 is the largest diameter size? any help would be great! thank you

Patient presents with several year history of enlarging right labial mass. It is nontender and well-circumscribed. Approximately 2 x 3 x 2 cm.

After verbal consent, lidocaine 1% was injected in the skin covering the lesion. An incision was made with #11 scalpel and pressure was applied to the lesion. No material extruded. Incision extended and with a combination of blunt and sharp dissection, the lesion was separated from surrounding tissue. Lesion removed intact, sent to pathology for evaluation. Deep portion of the incision closed with 4-0 Chromic in 2 stitches. Skin reapproximated with three figure-of-eight sutures.
 
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Korbc said:
hey everyone,

I'm not positive on lesion size for correct code for range 11400-11646. if anyone can help me. lesion is 2x3x2. are the 2's the margins and the 3 is the largest diameter size? any help would be great! thank you

Patient presents with several year history of enlarging right labial mass. It is nontender and well-circumscribed. Approximately 2 x 3 x 2 cm.

After verbal consent, lidocaine 1% was injected in the skin covering the lesion. An incision was made with #11 scalpel and pressure was applied to the lesion. No material extruded. Incision extended and with a combination of blunt and sharp dissection, the lesion was separated from surrounding tissue. Lesion removed intact, sent to pathology for evaluation. Deep portion of the incision closed with 4-0 Chromic in 2 stitches. Skin reapproximated with three figure-of-eight sutures.
Click to expand...
You report the code for the size that includes the largest lesion diameter plus any margins. If you have a 2 x 3 x 2 cm lesion, you use the largest dimension documented which is 3 cm to select the code (and I note that most physicians do not stipulate additional information about the margins they took, but the path report might with the sample size submitted). This is all spelled out quite well in your CPT book with illustrations.
 
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nielynco said:
You report the code for the size that includes the largest lesion diameter plus any margins. If you have a 2 x 3 x 2 cm lesion, you use the largest dimension documented which is 3 cm to select the code (and I note that most physicians do not stipulate additional information about the margins they took, but the path report might with the sample size submitted). This is all spelled out quite well in your CPT book with illustrations.
Click to expand...
thanks! yeah i had looked and read pg 89 but i didn't see anything mention about the certainty about what the placement of what the numbers represent, if every time the 1st and last number indicate the margins and the middle number represents the largest diameter. I just wanted to confirm this, thanks!
 
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They document as length x width x depth. So 2x3x2 cm is 2cm long, 3cm wide and 2cm deep. I'll add I have an issue with the "approximately" before the size. Approximately 3cm could mean 2.9cm which is a different code than 3.1cm.
I instruct my clinicians that the coders need to know the exact size of the excision performed (lesion plus margins). From a coding perspective, there are a few ways to do this.
Examples of wording that are clear to result in accurate coding of 2.6cm
1) Lesion of 2.2x1.1x.9 cm excised with a .2cm margin on all sides.
2) Excised 2.2x1.1x.9 cm lesion with a maximum excision diameter of 2.6cm
3) Excised 2.2x1.1x.9 cm lesion with incision of 2.6x1.5 cm.
Regardless of instruction, you will sometimes find clinicians who do not document clear enough. I HATE using the pathology measurements as specimen can often shrink once removed.
 
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csperoni said:
They document as length x width x depth. So 2x3x2 cm is 2cm long, 3cm wide and 2cm deep. I'll add I have an issue with the "approximately" before the size. Approximately 3cm could mean 2.9cm which is a different code than 3.1cm.
I instruct my clinicians that the coders need to know the exact size of the excision performed (lesion plus margins). From a coding perspective, there are a few ways to do this.
Examples of wording that are clear to result in accurate coding of 2.6cm
1) Lesion of 2.2x1.1x.9 cm excised with a .2cm margin on all sides.
2) Excised 2.2x1.1x.9 cm lesion with a maximum excision diameter of 2.6cm
3) Excised 2.2x1.1x.9 cm lesion with incision of 2.6x1.5 cm.
Regardless of instruction, you will sometimes find clinicians who do not document clear enough. I HATE using the pathology measurements as specimen can often shrink once removed.
Click to expand...
thanks so much!! and i think i asked this before but can't remember, but just out of curiosity for my own dorky science knowledge, does it still shrink when placed in formalin?
 
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Korbc said:
thanks so much!! and i think i asked this before but can't remember, but just out of curiosity for my own dorky science knowledge, does it still shrink when placed in formalin?
Click to expand...
Yes. I am not clinical by any standard, but my understanding is depending on the amount of tension in the area being excised, and how they are processed, some will minimally shrink, and some can significantly shrink. https://pubmed.ncbi.nlm.nih.gov/34459559/
 
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