How To Use CPT Code 56441

CPT 56441 describes the procedure for lysis of labial adhesions in females. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 56441?

CPT 56441 is used to describe the procedure of breaking fibrous bands that adhere to the external genitals in females. These adhesions can occur due to trauma, inflammation, or low levels of estrogen. The provider performs a lysis of labial adhesions by using sharp and/or blunt dissection to separate the fibrous adhesions of the labia majora and minora. The area is then irrigated, checked for bleeding, and sutures may be placed if necessary.

2. Official Description

The official description of CPT code 56441 is: ‘Lysis of labial adhesions.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider breaks the fibrous adhesions of the labia majora and minora using sharp and/or blunt dissection.
3. The area is irrigated and checked for bleeding.
4. If necessary, the provider places sutures.

4. Qualifying circumstances

CPT 56441 is performed on females who have fibrous bands adhering to their external genitals. These adhesions can be the result of trauma, inflammation, or low levels of estrogen. The procedure is typically done when the adhesions cause discomfort or interfere with normal bodily functions.

5. When to use CPT code 56441

CPT code 56441 should be used when a provider performs a lysis of labial adhesions in females. It is important to note that this code should only be reported once, even if the procedure is performed on both the left and right sides of the genital area.

6. Documentation requirements

To support a claim for CPT 56441, the provider must document the following information:

• Patient’s diagnosis and the need for lysis of labial adhesions
• Details of the procedure, including the use of sharp and/or blunt dissection
• Documentation of irrigation, bleeding checks, and sutures if placed

7. Billing guidelines

When billing for CPT 56441, ensure that the procedure is performed by a qualified provider. It is important to note that this is a bilateral procedure, so it should only be reported once, even if performed on both sides. There are no specific guidelines regarding reporting CPT 56441 with other codes.

8. Historical information

CPT 56441 was added to the Current Procedural Terminology system on January 1, 1991. There have been no updates to the code since its addition.

9. Examples

1. A gynecologist performs a lysis of labial adhesions in a 10-year-old girl who is experiencing discomfort and difficulty with urination.
2. A pediatric surgeon performs a lysis of labial adhesions in a 6-year-old girl who has recurrent urinary tract infections.
3. An obstetrician-gynecologist performs a lysis of labial adhesions in a 25-year-old woman who is experiencing pain during sexual intercourse.
4. A urologist performs a lysis of labial adhesions in a 40-year-old woman who is experiencing chronic pelvic pain.
5. A plastic surgeon performs a lysis of labial adhesions in a 30-year-old woman who is seeking cosmetic improvement of her external genitalia.
6. A dermatologist performs a lysis of labial adhesions in a 50-year-old woman who has developed adhesions as a result of chronic inflammation.
7. A family physician performs a lysis of labial adhesions in a 15-year-old girl who is experiencing menstrual irregularities.
8. An adolescent medicine specialist performs a lysis of labial adhesions in a 16-year-old girl who has not yet started menstruating.
9. A plastic surgeon performs a lysis of labial adhesions in a 35-year-old woman who is seeking relief from chronic itching and discomfort.
10. An obstetrician-gynecologist performs a lysis of labial adhesions in a 28-year-old woman who is experiencing difficulty with tampon insertion.