Excision Vulvar Abscesses

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Newport, VT
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Hello,
Can someone point me in the right direction for this, exam under anesthesia, resection/excision labial/vulvar abscesses? I came up with a few codes, but they don't exactly match up, 56405, Incision and drainage vulva abscess, or maybe 56605 biopsy of vulva lesion.
Quick summary of report,
The right labia majora had some separation with friable tissue. There were a couple more pinprick areas that drained clear fluid on the perideum.
Initially I began to debride some of the epithelialized area deep in the spot where the abscess had existed. After clearing some of that skin I was able to close the site with several interrupted sutures....
I then debrided the left abscess area. ...
Thank you for your input! Desiree
 

nielynco

Guru
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231
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Guadalupita, NM
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Hello,
Can someone point me in the right direction for this, exam under anesthesia, resection/excision labial/vulvar abscesses? I came up with a few codes, but they don't exactly match up, 56405, Incision and drainage vulva abscess, or maybe 56605 biopsy of vulva lesion.
Quick summary of report,
The right labia majora had some separation with friable tissue. There were a couple more pinprick areas that drained clear fluid on the perideum.
Initially I began to debride some of the epithelialized area deep in the spot where the abscess had existed. After clearing some of that skin I was able to close the site with several interrupted sutures....
I then debrided the left abscess area. ...
Thank you for your input! Desiree
Well if the patient had a diagnosis of necrotizing soft tissue infection (M72.6) you could report 11004, but it sounds like the abscess are cleared and he is doing some debridement plus a bit of suturing after. It also does not appear he did a complex repair so the 1313x codes would not apply (they do include debridement of the wound before suturing). None of the medical codes for debridement could be billed either. So it was not an I&D or a biopsy. You might be looking at a simple repair code for which you would have to have a size (1200x codes) or an unlisted code 58999 and you discuss with the physician which CPT code might best represent the amount of work. From what you have given us I do not think this was an intermediate repair.
 

nielynco

Guru
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Guadalupita, NM
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Hi
Per the description in CPT manual it states CPT 56440 marsuplization may be the best selection other than CPT 56405. What do you think?
Lady T
The procedure described does not involve a Bartholin gland cyst so this code would not be appropriate to bill. The physician might decide that the work involved in this otherwise unlisted procedure was equivalent, but the provider, not the coder should be making this decision.
 

TThivierge

Expert
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Atlanta, GA
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Hi
I agree with you the provider did not say Bartholin gland cyst which I did not pick that dx code. I do know the dx code N76.4 is exact describes problem from above description. The CPT 56440 best code because marsupialization term cleans out abscess then suture it up. In the clinical procedure marsupialization, the provider cuts a slit into a cyst on labia majora wall, allowing it to drain. Then, they suture the edges of the cyst to the surrounding tissue.
Lady T
 
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