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Posted By Mary Peabody on 02-28-2020, 11:50:32 in Ob-Gyn
Hello Melanie

Would you report CPT 15839 and 56605, 56606 for this surgery? The provider selected CPT 56620. Is this consider a labiaplasty? ACOG recommends for a labiaplasty to report 56620, but other coding resources recommend 15839

Persistent genital arousal disorder and clitoral phimosis
Post-op Dx: same
Procedure:clitoral hood revision, opening of vulvar scar

Procedure:
As soon as adequate general anesthesia was administered, the patient was put in dorsal lithotomy position in Allen stirrups with careful attention paid to neurologically safe postitioning. The perineal and lower abdominal area were prepped and draped.
1 cc lidocaine with epinephrine injected under clitoral hood and on superior vulva in are of prior incision
Scalpel used to open clitroal hood to level of clitoris and expose entire clitoris and gently take down all adhesions near base
Edges of hood closed with 4-0 monocryl and 4-0 nylon used to retract tissue to labia bilaterally
2 cm linear incision made in superior vulva in area of prior incision, small 3 mm wide tissue excised and edges closed with 4-0 monocryl and retraction sutured placed with nylon
1 mm biopsy done at perineum over lichenoid appearing tissue

FINAL PATHOLOGIC DIAGNOSIS
 
A. Anterior vulva, biopsy: Benign squamous epithelium with
hyperkeratosis and chronic inflammation.

B. Perineum, biopsy: Benign squamous epithelium with hyperkeratosis and
dermal fibrosis; see comment.

 
Comments (1)
Posted By Melanie Witt on 02-29-2020, 14:30:00
This was not a labiaplasty nor a vulvectomy. He freed up the clitoris and then removed scar tissue on the vulva. I would go with 11422 (as he made a 2 cm incision to remove the scar) and then 56605 , 56606 for the 2 Bx's. There is no code for the clitorial part of the surgery so you would have to report 58999. and maybe compare the work to 54162 even though this is a male procedure code (as the work involved is very similar to what he did for the clitoris).
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