Coding Q&A: Vulva
Disclaimer: Answers to incoming questions are provided by the members of the Society of Gynecologic Oncology (SGO) Coding and Reimbursement subcommittee and represent their opinion based upon the current and usual practices in the field. Every effort is made to ensure the accuracy of the information provided. However, the information neither replaces information in Medicare regulations, the CPT-4 code book, or the ICD-10 CM code book; nor does it constitute legal advice. Responses to questions are intended only as a guide and are not a substitute for specific accounting or legal opinions. SGO expressly disclaims all responsibility and liability arising from use of, or reliance upon this information as a reference source, and assumes no responsibility or liability for any claims that may result directly or indirectly from use of this information, including, but not limited to, claims of Medicare or insurance fraud.
How do you code for bilateral inguinal sentinel lymph node removal performed at the time of radical vulvectomy?
Billing depends on the dye that was injected and the procedures performed. The identification of the sentinel nodes with non-radioactive dye is reported using code 38900 (Intraoperative identification (e.g., mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed) with the 50 modifier for bilateral procedures. If the mapping is successful then use 38531 (biopsy/excision of inguinofemoral node(s) with modifier 50 if bilateral, as well as the code for complete (56633) or partial (56630) radical vulvectomy. If lymphadenectomy is required, then you can still use the mapping code (38900-50) but you should use the code that bundles radical vulvectomy with unilateral or bilateral lymphadenectomy (see codes 56631 – 56637).
How do you code for a partial urethrectomy done en bloc with a radical vulvectomy for vulvar cancer?
It would be reasonable to report code 53210 (Urethrectomy, total, including cystostomy; female) for the partial urethrectomy with the reduced services modifier 52. Code 53210 is not bundled into the vulvectomy codes (CPT 56620-56625 for simple vulvectomy, 56630-56637 for radical vulvectomy). If partial vaginectomy was performed add the appropriate code from 57106-57111.
How do you code for a skinning vulvectomy? Is it better to report code 56620 or a code from the integumentary section of CPT?
In general, it is better to be more specific for coding purposes. Codes 56620 and 56625 are specifically meant for vulvar procedures and should be used instead of integumentary codes.
The 80% rule applies. If you remove >80% of the total vulva, it is considered “Vulvectomy, simple complete” (56625). If <80% is removed, it is considered “Vulvectomy, simple partial (56620). Skin graft codes (CPT 14xxx-15xxx) can be billed in addition to vulvectomy codes if performed.
What is the most appropriate code for extramammary vulvar Paget’s disease?
D07.1 is the ICD 10 code for vulvar carcinoma in situ. The code does not specify the histologic type (squamous vs adeno). This is the most appropriate code for vulvar Paget’s disease i.e., adenocarcinoma in situ of the vulva. If there is invasion then the appropriate codes would be from the C51 series (Vulvar carcinoma, again without distinction for histologic subtype). There are 5 codes to choose from depending on the anatomic location of the primary tumor.
What is the code for scalpel excision and cauterization of a 2 cm condyloma growing out of the distal urethra?
You should report a code from the 11420-6 f=group (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia;). Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). For a 2 cm lesion the excised diameter is likely to be greater than 2 cm and so would most likely be code 11423 (excised diameter 2.1 to 3.0 cm).
Nuclear medicine injects the vulva preop with technetium sulfur colloid. A lymphoscintigram is done. They bill for both the injection and the imaging. The patient comes up to the OR. I inject the vulvar malignancy with blue dye -4 subdermal injections at 12,3,6,9. I have been using 38900. Can I bill for 4 injections or just one?
38900 is the CPT code for “intraoperative identification (e.g., mapping) of sentinel node(s) includes injection of non-radioactive dye, when performed. This means it can be billed twice using the -50 modifier if both right and left groin sentinel nodes are mapped. The code is not solely for the intratumoral injection, but for the mapping as well.
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