Ob-Gyn Coding Alert

Dig Up Reimbursement for Lesion Removal

Published on Sun Dec 01, 2002 Updated on Sun Dec 01, 2002

Because gynecological lesions can appear on several different female genital organs, apply the coding rules for removal from multiple sites to ethically optimize reimbursement.

Lesions can be present on the vulva, vagina, cervix and anus, among other sites, and can be removed in one of two ways excision or destruction. When the ob-gyn excises a lesion, he or she cuts it away from the surrounding tissue and sends it for pathological examination, says Mary Mulholland, RN, BSN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia.

Destruction involves breaking down the lesion by any number of methods, including chemical and laser treatment, and electro- and cryosurgery. During cryosurgery, the physician freezes the lesion off using liquid nitrogen or carbon dioxide. The lesion is destroyed, and no biopsy is conducted. With routine and recurrent vaginal warts, the ob-gyn commonly uses a destruction method for removal.

Consider Location, Number and Method for Destruction

Several coding options exist for destruction of female genital lesions. Some coders may attempt to search the destruction codes (17000-17004), but you must consider many factors to determine the appropriate code the lesion(s) location, the number of lesions and the destruction method. The physician's operative note should clearly identify the size of the largest lesion, number and location, says Harry L. Stuber, MD, an independent gynecologist in Cookeville, Tenn.

The codes for lesion destruction include the following:

46900* Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical

46910* electrodesiccation

46916 cryosurgery

46917 laser surgery

46922 surgical excision

46924 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery)

56501 Destruction of lesion(s), vulva; simple (e.g., laser surgery, electro-surgery, cryosurgery, chemosurgery)

56515 extensive (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery)

57061 Destruction of vaginal lesion(s); simple (e.g., laser surgery, electro-surgery, cryosurgery, chemosurgery)

57065 extensive (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery)
Note: Coders might be tempted to use codes from CPT's Destruction" Benign or Premalignant Lesions" section (17000 series). But you should use the codes for the anatomic site rather than the 17000 codes whenever possible CPT states.

If the ob-gyn destroys multiple lesions on both the vulva and vagina you should use 57065 and 56515 appended with modifier -51 (Multiple procedures) Mulholland says. Also based on CPT's definitions if the ob-gyn destroys the lesion by applying trichloroacetic acid (TCA) you should use the above codes.

The lesions' number and size define the difference between "simple" and "extensive." As a rule of thumb you should consider more than a few lesions as an "extensive" destruction Mulholland says. If the lesions are large and significantly raised off the skin's surface and require more time and/or chemicals to remove you may also apply the extensive codes. The American College of Obstetricians and Gynecologists (ACOG) states that 56501 includes destroying simple or single lesion(s). If a patient has more than two or three genital-area lesions you should use 56515.

You should remember however not to confuse chemical irrigation of the vaginal area with chemical destruction of vaginal lesions. Some coders may be tempted to use 57150* (Irrigation of vagina and/or application of medicament for treatment of bacterial parasitic or fungoid disease) for the destruction of vaginal warts (a type of lesion). But this procedure does not match the diagnosis. Venereal warts or condyloma are a viral manifestation and you should report 57150 only when the physician treats bacterial parasitic or fungoid disease. In addition 57150 involves the ob-gyn using a catheter or similar tube high in the vaginal canal to flush it with a medicated solution not the direct application to the affected area as with a chemical destruction.

Location and Biopsy Are Key for Excision Coding

Occasionally ob-gyns must use surgery to remove large lesions that have not responded to other forms of treatment Stuber notes. For female genital lesion excision you may choose from several codes depending on the location and whether the physician orders a biopsy of the excised tissue:

11420 Excision benign lesion except skin tag (unless listed elsewhere) scalp neck hands feet genitalia; lesion diameter 0.5 cm or less (For larger benign lesion excision use 11421-11426 depending on the size.)

57100* Biopsy of vaginal mucosa; simple (separate procedure)

57105 extensive requiring suture (including cysts)

57500* Biopsy single or multiple or local excision of lesion with or without fulguration (separate procedure).

For example the ob-gyn surgically removes a 1.3-cm vaginal wart for biopsy. You should code the procedure with 11422 ( lesion diameter 1.1 to 2.0 cm) or 57500. Code 11422 has a slightly higher relative value.

Note: CPT 2003 revises the skin lesion codes (11420-11426) so they clearly describe a full-thickness removal of the lesion which includes the margins along with simple closure (if performed).

Don't Forget Diagnostic Factors

As with some sexually transmitted diseases like genital herpes the patient still carries the human papillomavirus (HPV) even when she is not exhibiting any symptoms. But vaginal or genital warts can be diagnosed in patients only when the symptoms are present. The ob-gyn can usually diagnose warts by visual examination and a Pap smear can confirm the diagnosis. A colposcopy (57452) can also help the physician detect HPV or condylomata in the vaginal interior. In some cases the ob-gyn may need to perform a biopsy of the cervical tissue.

When linking diagnostic codes to the lesion destruction or excision procedures you should use the following:

078.10 Viral warts unspecified

078.11 Condyloma acuminatum

078.19 Other specified viral warts

091.3 Secondary syphilis of skin or mucous membranes

623.8 Other specified noninflammatory disorders of vagina (including cyst of vagina)

621.9 Unspecified disorder of uterus.

Additionally the HPV causing the warts should be identified as the viral agent and coded 079.4 (Human papillomavirus). This serves as the secondary diagnosis for the lesion code.

Code Completely to Ensure Proper Reimbursement

You should remember that when coding for in-office vaginal lesion removal you can report both the destruction or excision of the lesion and an E/M visit for a new or established patient (99201-99215) if an E/M service is separate and significant from the procedure Mulholland says. For example the ob-gyn diagnoses and treats a new patient's vaginal lesions during her first visit. You could report the treatment as well as 99203 if the physician documents at least a detailed history detailed examination and medical decision-making of low complexity.

You should append modifier -25 (Significant separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code to indicate that the E/M service is separate from the lesion removal. On the other hand if the ob-gyn prescribes a topical medication for the patient to apply at home you should report only the E/M visit.