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Posted By Maria on 02-13-2018, 20:14:18 in Ob-Gyn
Hello Melanie,

One more please.

I think the radical vulvectomy is CPT 56631. This code would also include the lymph node dissection.

I am totally thrown on the CPT for the rhomboid skin flap harvesting. . Not sure what type of graft this is.

1. Radical Vulvectomy
2. Left Groin Lymph node dissection
3. 4 x 4 cm rhomboid skin flap closure

100 mL
65 yo with vulvar carcinoma here for OR therapy
5 x 6 cm left vulvar lesion near clitoris. Left groin nodes - neg on frozen.
Vulva, Groin lymph nodes
After assuring informed consent the patient was taken back to the operating suite and induction of anesthesia was done. The patient was placed in the modified dorsal lithotomy position in Allen stirrups then prepped and draped in the normal sterile fashion.
Attention was then turned to the left groin. A 15 blade scalpel was used to make an incision in the skin overlying the groin between the ASIS and pubic bone. The underlying subcutaneous tissue was dissected with a metzenbaum scissors. The superficial lymph nodes were dissected out with the boundaries of the dissection being the inguinal ligament superior, adductor longus muscle inferior and sartorius muscle lateral. These nodes were sent to pathology. The deep femoral lymph nodes were dissected out and found just medially and deep to the femoral vein. Care was taken to find the femoral vein as well as the saphenous vein. These nodes were sent as deep inguinal lymph nodes. The groin was irrigated with normal saline. A 10 round JP drain was placed in this space. The deep tissue was reapproximated with 2-0 vicryl and the skin was closed with 4-0 vicryl in a subcuticular stitch.
Attention was then taken to the vulva. A marking pen was used to mark out the area of excision. A 10 blade scalpel was used to cut the area for dissection and a bovie cautery was used to carry the dissection down to the fascia. This area of vulva was completely excised and hemostasis was obtained with the bovie as well as interrupted 2-0 vicryl stitches. A 4 x 4 cm rhomboid skin flap was dissected out and used to close over the vulvar defect. Deep sutures of 2-0 vicryl were placed. The skin was reapproximated with 2-0 vicryl in vertical mattress fashion as well as interrupted single stitch fashion. Foley catheter was placed. Sponge, lap, needle count and instruments were correct x 2. The patient went to the recovery room in stable condition.

Thanks once again, Maria
Comments (1)
Posted By Melanie Witt on 02-15-2018, 21:29:06
A rhomboid flap refers to the shape of the flap. Probably the best code for this would be 15574 because the reference to genitalia refers to the recipient area not the donor site. But this code applies to a non-adjacent tissue transfer and this op note does not give this information. An adjacent tissue transfer to this area would be 14040 instead so I would consult with your provider to clarify.
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