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!!
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