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inswiz 11-05-2010 09:09 AM

vulvar biopsy
 
What content should a procedure note contain when a vulvar biopsy(56605) is done? One of our providers documented "There is an area of white epithelium in her posterior fourchette; and after a time-out was taken per protocol, a vulvar biopsy was accomplished with a grasping forceps." Thank you for any information.

preserene 11-05-2010 09:40 AM

From the info you provided it seems the diagnosis code is Other Dystrophy of the vulva, Leukoplakia of vulva.- diagnosis code 624.09 (A noninflammatory lesion of the Vulva)

The CPT code, whatever method she used, it is a biopsy of the vulva -56605, Biopsy of vulva or perinium , one lesion.

So the doctor's note should contain the diagnosis as I said earlier or what ever she wishes to document (she is the final authority) with notes saying to rule out noepasia of the vulva
because the dystrophy of the vulva could be a predisposing condition for vulvar Intraepithelial Neoplasia.
Unless and until it is proved so, this scenario is for a benign lesion (Leukoplakia volva) and the procedure is biopsy Vulva

I have given a gist of the necessary words in the document but it is our duty to code as they document.
No documentation by the physician, it never happened!!

dan528i 10-31-2011 11:40 AM

Hello Everyone !

I need help to code the a Vulva Biopsy. So I am guessing 56605 with 625.8. Then the report states that Dr. removed a total of 10 masses. So what i did was 56605 for the first one and 56606 x 9 for the rest. Can someone confirm that this is correct.

Thanks a lot

ajs 10-31-2011 12:19 PM

Quote:

Originally Posted by dan528i (Post 186338)
Hello Everyone !

I need help to code the a Vulva Biopsy. So I am guessing 56605 with 625.8. Then the report states that Dr. removed a total of 10 masses. So what i did was 56605 for the first one and 56606 x 9 for the rest. Can someone confirm that this is correct.

Thanks a lot

Yes for the CPT codes but I would use 624.8 for the diagnosis code. This refers to cyst of the vulva. It is "Other specified noninflammatory disorders of the vulva and perineum". The brackets under the description indicate cyst, edema, stricture of vulva.

dan528i 10-31-2011 12:22 PM

thanks Arlene.

Can you point me towards a documentation by any chance. Only because I need to send an appeal to GHI So I was hopping to include something in writing so that they can process the appeal correctly.

Again Thanks for your help.

ajs 10-31-2011 12:43 PM

Quote:

Originally Posted by dan528i (Post 186363)
thanks Arlene.

Can you point me towards a documentation by any chance. Only because I need to send an appeal to GHI So I was hopping to include something in writing so that they can process the appeal correctly.

Again Thanks for your help.

Were you needing documentation for the CPT codes? If so, the actual description in the CPT book is your best documentation. If the description in the codes matches what the physician documented, that is all you should need to clarify what was done. That is, if the physician actually biopsied each lesion. If the physician actually did a destruction of lesions, then that is a different code. If the biopsy was done, you should have a pathology report that lists the lesions and the results. That would also be used in your appeal.

dan528i 10-31-2011 12:46 PM

Sounds good
thank again


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