James Burke, MD
Over the years treatment of vulvar diseases has changed dramatically. The treatment of pre-invasive disease has become less extensive, with the en block “longhorn” resection largely being replaced by more localized radical excisions, with or without inguinal lymphadenectomy or sentinel lymph node biopsies. Several Current Procedural Terminology (CPT) codes exist to reflect the work of these procedures as well as complex wound closures. Below are several case vignettes illustrating coding for these vulvar procedures.
Case 1: The patient is a 41 year old female with multi-focal (four separate lesions) VIN III. You treat the patient with CO2 laser destruction of the lesions. The most appropriate code for her treatment would be
56515, extensive destruction of vulvar lesions, any method, due to the number of lesions being treated.
- What is the difference between destruction of vulvar lesions, simple (CPT-56501) versus extensive (CPT-56515)?
For these codes, CPT makes no reference as to what constitutes a simple treatment versus one that is extensive. In this scenario, the physician makes the determination and chooses the code he/she feels is most appropriate. Time, effort, complexity of the therapy, number of lesions, size of the lesions (several isolated lesions versus one large contiguous cluster) and risk should all be taken into consideration in making the final code selection. And of course, if you go with the extensive codes, be sure you document as completely as possible (i.e. size and number of lesion(s) and time spent to ablate those lesions) so that your choice of code is clearly supported by your documentation.
Case 2: The patient is a 49-year-old female with extensive VIN III/CIS of the vulva encircling the posterior introitus (about 50% of the vulva). The patient is taken for a simple partial vulvectomy with split thickness skin grafting for coverage of 110 sq cm. The appropriate vulvectomy code would be a simple, partial vulvectomy (CPT-56620).
- This code is utilized because less than 80% of the vulva is being removed. The procedure is a simple vulvectomy due to the depth of the resection; only the skin and immediate underlying subcutaneous tissue are removed. This procedure used to be called a “skinning vulvectomy.”The billing for split-thickness skin grafting is based upon the size of the defect to be covered in square centimeters (cm2); however, the dimensions of the donor site are NOT added to the size of the defect to be covered. In this example, the size of the defect is 110 square centimeters, the primary CPT code is 15120 and covers the first 100 cm2 or less. A secondary, add-on code is also billed (CPT-15121) which covers the additional 10 cm2 (up to a total of an additional 100 cm2). Since all of these CPT codes are affected by multiple procedure reduction guidelines (except the add-on code), CPT 15120 code is listed first (wRVUs of 10.15), followed by the partial vulvectomy code (56620-wRVUs-3.77 [50% of 7.53]) and the secondary split thickness code (15121-wRVUs-2.00-no reduction since it is an ad-on code).
Case 3: A 68-year-old female has a biopsy proven, 2 cm, posterior fourchette, grade 2 squamous cell carcinoma of the vulva. She underwent a partial radical vulvectomy, bilateral inguinal sentinel lymph node biopsies and bilateral rhomboid flaps (each 4 x 4 cm) to close the posterior defect. To code this procedure, the most appropriate vulvectomy code is 56630, partial radical vulvectomy, since less than 80% of the vulva was removed. The code for sentinel lymph node biopsies is 38531 and is appended with the bilateral procedure modifier, -50. The intraoperative lymphatic mapping code, 38900+, is an add-on code to the primary lymph node biopsy CPT and also is appended with the bilateral modifier, -50 since injections for mapping were done on each side of the vulva.
- CPT codes that can be bilateral are billed once with the -50 modifier and are paid at 150% of the baseline wRVU of the code. Because the procedure is being done at the same session, but in bilateral locations, the pre- and post-operative care occurs one time for the patient. Hence the reason for the payment to be 150% of wRVUs for bilateral procedures. The add-on code, 38900+, is a code that cannot be billed by itself and needs to be “added on” to a primary procedure, such as the lymph node biopsy code mentioned. Add-on codes are NOT subject to the multiple procedure reduction guidelines since they cannot stand alone as billable codes. The tissue transfer CPT is billed based upon the size of the defect to be covered. In this case it is 16 cm2 and the most appropriate CPT code is 14041 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet for a defect 10.1 cm2 to 30.0 cm2). This code is billed twice since the flap was developed from two different areas to cover the defect (both sides of the fourchette). A bilateral modifier (-50) is not appropriate (or necessary) for these procedures and the codes are valued at full value for each billable entry. However, these codes are subject to the multiple procedure reduction guidelines. In this example, the vulvectomy code would be billed first (56630-wRVUs-14.8). Because the lymph node biopsy code (38531, modifier-50) is a bilateral code, it would firstly be valued at 10.11 wRVUs (which is 150% of 6.74 wRVUs of the base code). It would then be reduced as the second procedure (38531-wRVU 5.06 [50% of 10.11]). The lymphatic mapping would also be valued at 150%, but not reduced since it is an add-on code (38900+-wRVUs-3.75 [150% of 2.5]). Finally, the adjacent tissue transfer for 16 cm2 each, would be billed twice (14041-wRVUs-21.66 [10.83 x 2]), but would be reduced by 50% as the third procedure (14041-wRVUs-10.83 [50% of 21.66]).
James J. Burke, II, MD, is a Gynecologic Oncologist at Mercer University School of Medicine in Savannah, GA.