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Reporting N75.0 for a cyst located on the vulva could be a mistake.

Vulvar cysts and abscesses can look similar in the documentation, but the diagnosis and procedure performed can lead you to very different code choices. For instance, a Bartholin gland cyst is not the same as a nonspecific vulvar cyst, and you would not code drainage of a Bartholin abscess the same way as drainage of a non-Bartholin vulvar abscess.

How should you navigate these claims? The key is to identify the exact anatomic site, determine whether the ob-gyn documented a cyst or abscess, and then match the procedure to the work the ob-gyn actually performed. This distinction becomes especially important when the ob-gyn performs aspiration, incision and drainage, Word catheter placement, marsupialization, or excision.

Start With the Anatomic Site

Your first step is to determine exactly where the lesion is located.

The distinctions are supported by the ICD-10-CM code set. The N75.- (Diseases of Bartholin’s gland) category specifically identifies diseases of the Bartholin gland. A Bartholin gland cyst has its own ICD-10-CM code, N75.0 (Cyst of Bartholin’s gland). A Bartholin gland abscess is separately classified as N75.1 (Abscess of Bartholin’s gland).

However, for a vulvar cyst that is not documented as involving the Bartholin gland, you may report N90.7 (Vulvar cyst). Meanwhile, a vulvar abscess that is not identified as a Bartholin gland abscess is reported with N76.4 (Abscess of vulva).

It’s important to remember not to treat every vulvar cyst as a Bartholin cyst.

Example: Your ob-gyn documents a 1.5 cm inclusion cyst of the left labia majora. The lesion is not associated with the Bartholin gland. For this scenario, you would report N90.7.

Watch out: Do not assign N75.0 simply because the cyst is located on the vulva. The documentation must support a Bartholin gland origin.

Match Drainage to the Procedure Performed

Once you establish the diagnosis, turn to the procedure note.

For a Bartholin gland abscess, CPT^® provides a specific code: 56420 (Incision and drainage of Bartholin’s gland abscess). For a general vulvar or perineal abscess, the applicable code is 56405 (Incision and drainage of vulva or perineal abscess).

Example: A patient presents with a painful right Bartholin gland abscess. The ob-gyn makes an incision, drains the purulent material, irrigates the cavity, and places a Word catheter.

For this example, you would report 56420 with an ICD-10-CM code of N75.1.

Heads up: Do not separately report a code for the Word catheter simply because the physician placed it. The catheter placement is part of the drainage treatment described for a Bartholin gland abscess rather than a separately reported procedure.

The American College of Obstetricians and Gynecologists (ACOG) identifies drainage with Word catheter placement as a standard treatment approach for Bartholin gland cysts and abscesses.

Distinguish Aspiration From Incision and Drainage

A needle aspiration is not the same procedure as an incision and drainage (I&D).

Code 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst) describes aspiration using a needle rather than opening the lesion through an incision.

However, you should not automatically use 10160 simply because the physician mentions a needle in the procedure note. Determine whether the physician actually performed a puncture aspiration and whether a more specific code applies to the anatomic site and condition.

Example: The ob-gyn evaluates a symptomatic vulvar cyst that is not identified as a Bartholin gland cyst. The physician inserts a needle and aspirates the cyst contents. The ob-gyn makes no incision and performs no catheter or marsupialization.

If the documentation supports the service and no more specific CPT^® code applies, 10160 may describe the procedure.

You would assign N90.7 as the diagnosis code if the ob-gyn documents a vulvar cyst.

Important: Do not report an I&D code when the physician only performed needle aspiration.

Recognize When Marsupialization Changes the Code

Marsupialization is more than simple drainage. During the procedure, the ob-gyn opens the cyst and sutures the cyst wall to adjacent tissue to create a continuing drainage opening. Code 56440 (Marsupialization of Bartholin’s gland cyst) specifically describes this procedure.

ACOG describes marsupialization as an option for symptomatic Bartholin cysts and abscesses, particularly in certain recurrent or larger cases. The procedure involves opening the cyst or abscess and suturing the cyst wall to the surrounding tissue to maintain drainage.

Example: A patient has a recurrent symptomatic Bartholin gland cyst. The ob-gyn makes an incision, drains the cyst, opens the cavity, and sutures the cyst wall to the adjacent tissue.

For this scenario, you would report 56440 with N75.0 as the diagnosis code.

Do not report 56420 simply because the physician opened and drained the cyst. The operative technique documented is marsupialization, which has its own CPT^® code.

Code Excision According to the Lesion and Procedure

Excision requires another important distinction. Ask yourself, are you dealing with a Bartholin gland or cyst, or a separate benign vulvar lesion?

Code 56740 (Excision of Bartholin’s gland or cyst) is the site-specific code to consider when the documentation supports excision of the Bartholin gland or cyst.

ACOG notes that excision of the Bartholin gland may be considered for recurrent abscesses, solid masses, or concern for malignancy. ACOG also recommends evaluation of a Bartholin gland mass in patients older than 40 because of the increased concern for malignancy.

For a separate benign vulvar lesion, you may instead need to look to the integumentary lesion excision codes. For example, you might report 11422 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm). The exact code depends on the documented excised diameter and the nature and location of the lesion.

Example: The ob-gyn documents a 1.5 cm benign-appearing cyst of the labia majora that is not a Bartholin cyst. The physician excises the entire lesion and submits it for pathology.

The procedure documentation supports consideration of 11422. The diagnosis may be N90.7.

The operative report should support the lesion’s location, size, and complete excision. Do not substitute the Bartholin-specific excision code unless the documentation identifies the lesion as involving the Bartholin gland.

Do Not Confuse Bartholin and Vulvar Abscesses

One of the easiest mistakes you can make is choosing the general vulvar abscess code when the provider clearly documents a Bartholin gland abscess.

Consider this documentation: “Fluctuant 3 cm abscess of the right Bartholin gland. Incision made with evacuation of purulent material.”

For this scenario, you would report the following codes:

• 56420
• N75.1

By contrast, consider this provider documentation: “2 cm abscess of the right labia majora. Incision and drainage performed. No involvement of Bartholin gland.” In this case, you would report the following codes:

• 56405
• N76.4

The diagnosis and procedure codes should tell the same clinical story.

Remember to Verify the Documentation Before You Code

When you encounter a vulvar cyst or abscess, work through the documentation systematically by following these steps:

• Identify the anatomic site.
• Determine whether the lesion involves the Bartholin gland.
• Distinguish a cyst from an abscess.
• Identify whether the physician aspirated, incised and drained, placed a catheter, marsupialized, or excised the lesion.
• Look for a procedure code that specifically describes the documented service.
• Verify the ICD-10-CM code in the Tabular List, including applicable instructional notes.
• If the documentation does not establish the site, diagnosis, or procedure performed, follow your organization’s compliant query process.
• Do not infer a Bartholin diagnosis from the location of a lesion alone. Likewise, do not assume that every procedure described as “drainage” represents an I&D service.

Keep the Diagnosis and Procedure Aligned

Vulvar and Bartholin coding becomes much easier when you separate the diagnosis from the procedure and then bring the two back together.

A Bartholin cyst points you toward N75.0.

A Bartholin abscess points you toward N75.1.

A nonspecific vulvar cyst may support N90.7, while a vulvar abscess may support N76.4. The procedure then depends on what the ob-gyn actually performed, such as 56420 for Bartholin abscess drainage, 56440 for Bartholin cyst marsupialization, or 56740 for excision of the Bartholin gland or cyst.

Your goal is not simply to find a code that sounds similar to the documentation. You need to make sure the code accurately represents both the condition being treated and the work the physician performed.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor