How To Use CPT Code 56440

CPT 56440 describes the marsupialization procedure for treating a Bartholin’s gland cyst in the female genital area. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 56440?

CPT 56440 is used to describe the marsupialization procedure for treating a Bartholin’s gland cyst. This procedure involves incising the cyst and sewing its edges to adjacent tissues, creating an open pouch that allows for continuous drainage. By doing so, the procedure reduces pain and prevents the recurrence of the cyst.

2. Official Description

The official description of CPT code 56440 is: ‘Marsupialization of Bartholin’s gland cyst.’

3. Procedure

1. The provider preps and anesthetizes the patient.
2. The labia are taped back to ensure visibility of the entire opening.
3. An incision is made over the mucosa of the Bartholin’s cyst to expel its contents.
4. The walls of the cyst are clamped and sutured into the hollow opening, creating an open pouch.
5. The area is irrigated, checked for bleeding, and dressed.

4. Qualifying circumstances

CPT 56440 is performed on patients with a Bartholin’s gland cyst, which is a fluid-filled sac in the female genital area. The procedure is indicated to reduce pain and prevent the recurrence of the cyst. It is important to note that this procedure is specific to the Bartholin’s gland cyst and should not be confused with incision and drainage of an abscess in a Bartholin’s gland, which is reported with a different CPT code (56420).

5. When to use CPT code 56440

CPT code 56440 should be used when performing the marsupialization procedure for a Bartholin’s gland cyst. It is important to ensure that the procedure is specifically targeted at the cyst and not an abscess. If the provider performs incision and drainage of an abscess in a Bartholin’s gland, a different CPT code (56420) should be reported.

6. Documentation requirements

To support a claim for CPT 56440, the following documentation is required:

• Patient’s diagnosis of Bartholin’s gland cyst
• Description of the procedure performed, including the incision and suturing of the cyst
• Date of the procedure
• Any additional relevant information, such as complications or follow-up plans

7. Billing guidelines

When billing for CPT 56440, ensure that the procedure performed is marsupialization of a Bartholin’s gland cyst. It is important to distinguish this procedure from incision and drainage of an abscess in a Bartholin’s gland (reported with CPT code 56420). There are no specific guidelines regarding reporting CPT code 56440 with other codes.

8. Historical information

CPT 56440 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A provider performs marsupialization of a Bartholin’s gland cyst for a patient experiencing recurrent pain and discomfort.
2. A patient presents with a Bartholin’s gland cyst, and the provider decides to perform the marsupialization procedure to prevent future recurrences.
3. A Bartholin’s gland cyst is diagnosed in a patient, and the provider recommends marsupialization to alleviate pain and prevent complications.
4. A patient undergoes marsupialization of a Bartholin’s gland cyst as part of their treatment plan for a recurring cyst.
5. A provider performs the marsupialization procedure on a patient with a Bartholin’s gland cyst to improve their quality of life and prevent further discomfort.
6. A patient with a Bartholin’s gland cyst undergoes marsupialization to ensure proper drainage and reduce the risk of infection.
7. A provider performs the marsupialization procedure on a patient with a Bartholin’s gland cyst to alleviate pain and improve their overall well-being.
8. A patient with a Bartholin’s gland cyst undergoes marsupialization to prevent the cyst from recurring and causing further complications.
9. A provider performs the marsupialization procedure on a patient with a Bartholin’s gland cyst to improve their comfort and prevent future discomfort.
10. A patient undergoes marsupialization of a Bartholin’s gland cyst to ensure proper drainage and reduce the risk of infection.