Results 1 to 7 of 7

vulvar biopsy

  1. #1
    Question vulvar biopsy
    Medical Coding Books
    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.

  2. Default
    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!!

  3. Default
    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

  4. #4
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by dan528i View Post
    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.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  5. Default
    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.

  6. #6
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by dan528i View Post
    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.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  7. Default
    Sounds good
    thank again

Similar Threads

  1. Vulvar Skin Tag
    By acleveland@wcotb.com in forum OB/GYN
    Replies: 3
    Last Post: 02-21-2013, 03:33 PM
  2. Vulvar vein phlebectomy
    By conniecoder in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 01-11-2013, 01:59 PM
  3. path for vulvar biopsy
    By pscott in forum OB/GYN
    Replies: 2
    Last Post: 09-25-2012, 03:11 PM
  4. vulvar biopsy-Please help!
    By pscott in forum Pathology & Clinical Laboratory
    Replies: 2
    Last Post: 09-25-2012, 03:09 PM
  5. excision of vulvar mass
    By jmelizon in forum OB/GYN
    Replies: 4
    Last Post: 08-25-2011, 10:29 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.