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I&D vaginal cyst, not documented as Bartholin nor infected.

  1. #1
    Location
    Lebanon, New Hampshire
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    31
    Default I&D vaginal cyst, not documented as Bartholin nor infected.
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    Provider saw a patient with a vaginal cyst and utilized a punch bx to incise and drain the cyst, drainage was not sent for culture. The documentation does not refer to the cyst as a Bartholin nor that it was infected, although the cyst is near the anatomical region for a Bartholin cyst; waiting for the provider to confirm. In the meantime, the only "vaginal" cyst codes I can find relate specifically to a Bartholin cyst. What code for vaginal cyst drainage would I use if this turns out not to be a Bartholin cyst....any ideas?

    Also, can't seem to find a code for vaginal mucous tag removal....

    Any help would be appreciated.

  2. Default
    I would code with 623.8, hope this helps.

  3. #3
    Default
    624.8 is Cyst, labium. (Also sebaceous cyst of labia/vulva)

    I'd only go with 623.8, if the location is specified as being in the vagina, and not on the external genitalia.

  4. #4
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    Quote Originally Posted by Rita B. Conley View Post
    Provider saw a patient with a vaginal cyst and utilized a punch bx to incise and drain the cyst, drainage was not sent for culture. The documentation does not refer to the cyst as a Bartholin nor that it was infected, although the cyst is near the anatomical region for a Bartholin cyst; waiting for the provider to confirm. In the meantime, the only "vaginal" cyst codes I can find relate specifically to a Bartholin cyst. What code for vaginal cyst drainage would I use if this turns out not to be a Bartholin cyst....any ideas?

    Also, can't seem to find a code for vaginal mucous tag removal....

    Any help would be appreciated.
    I have a stupid question...is the cyst in question the vaginal mucous tag? ICD-9 kind of points to the same codes for both descriptions. If so, I'd say to code the procedure as 56405 (I&D of vulva or perineal abcess), or 57100 or 57105 for biopsy of vaginal mucosa, depending on where it was.

  5. #5
    Location
    Lebanon, New Hampshire
    Posts
    31
    Default
    Hi. It's the CPT code I need help with....any advice there?

  6. #6
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    Quote Originally Posted by Rita B. Conley View Post
    Hi. It's the CPT code I need help with....any advice there?
    Not without a specific location - there are different codes for each situation/location (vulva/vaginal/labial/Skene's/sebaceous/etc.) Sorry.

  7. #7
    Location
    Lebanon, New Hampshire
    Posts
    31
    Default
    Unfortunately, with the cyst in the vagina, it's not documented as infected and after it was incised and drained, the specimen wasn't sent for culture, so neither of the codes you mentioned will work....this is why I'm stuck right now.

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