Ob-Gyn Coding Alert

Question: A 15-year-old patient was diagnosed with clitoromegaly and labial enlargement. An incision was made across the labia in an inverted V shape. The underlying fibromuscular tissue was dissected off the labial mucosa, bilaterally to isolate the clitoris. The crura of the clitoris were also dissected, and excess labial skin was removed. How should this surgery be coded?

Arizona Subscriber

 
Answer: Code 56805 (Clitoroplasty for intersex state) is the best code, considering the patients age (it sounds like this condition may be congenital).
 
You can add a second code for the excess labial skin removal (15839, Excision, excessive skin and subcutaneous tissue [including lipectomy]; other area) or add modifier -22 (Unusual procedural services) to the clitoroplasty code.
 
As far as the diagnoses, the conditions you have identified may link to 56805:
 
If you report 624.2 (Hypertrophy of clitoris), the condition would not be congenital or of an endocrine origin, which is what the clitoroplasty procedure is intended to address.
 
If you report 255.2 (Adrenogenital disorders) because the condition is of an endocrine origin, this diagnosis should link to code 56805 without resistance from the carrier.