How To Use CPT Code 56620

CPT 56620 describes a surgical procedure known as a simple vulvectomy, which involves the removal of all or part of the vulva for benign or premalignant conditions that are extensive or numerous. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 56620?

CPT 56620 is a code used to describe a surgical procedure called a simple vulvectomy. This procedure involves the removal of all or part of the vulva for conditions of the vulva that are extensive or numerous and cannot be treated with local excision of a discrete lesion. It is important to note that this procedure is performed for benign or premalignant conditions.

2. Official Description

The official description of CPT code 56620 is the following: ‘Vulvectomy simple; partial.’

3. Procedure

1. The patient is positioned in the dorsal lithotomy position, with knees bent and spread apart using stirrups.
2. The physician administers a general anesthetic to the patient.
3. The physician marks the area to be excised and makes an oval-shaped incision around the affected portion of the vulva.
4. The physician removes the affected skin, mucous membrane, and any superficial fat and connective tissue.
5. Pudendal vessels are securely tied and bleeding is controlled using electrocautery.
6. Packing may be placed in the vagina if necessary.
7. The defect is closed using synthetic absorbable sutures, and a skin graft may be used if the area is large and cannot be closed with sutures alone.

4. Qualifying circumstances

CPT 56620 is performed for benign or premalignant conditions of the vulva that are extensive or numerous and cannot be treated with local excision of a discrete lesion. It is important to note that this procedure involves the removal of less than 80% of the vulva, targeting specific affected portions such as the labia minora, labia majora, clitoris, and surrounding tissues.

5. When to use CPT code 56620

CPT code 56620 should be used when a simple vulvectomy is performed for benign or premalignant conditions of the vulva that are extensive or numerous. It is important to ensure that the procedure involves the removal of less than 80% of the vulva and that it cannot be treated with local excision of a discrete lesion.

6. Documentation requirements

To support a claim for CPT 56620, the following documentation is required:

• Documentation of the patient’s diagnosis and the need for a simple vulvectomy
• Details of the procedure performed, including the specific portions of the vulva removed
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed, such as the use of a skin graft
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 56620, it is important to ensure that the procedure meets the criteria for a simple vulvectomy and that it is performed for benign or premalignant conditions of the vulva that are extensive or numerous. It is also important to follow any specific guidelines provided by the payer regarding documentation and coding for this procedure.

8. Historical information

CPT code 56620 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient undergoes a simple vulvectomy to remove a premalignant lesion on the labia minora.
2. A physician performs a partial vulvectomy to treat an extensive benign condition affecting the labia majora.
3. A simple vulvectomy is performed on a patient with multiple premalignant lesions on the vulva.
4. A woman undergoes a partial vulvectomy to remove a large benign growth on the clitoris.
5. A simple vulvectomy is performed on a patient with extensive premalignant changes throughout the vulva.
6. A physician performs a partial vulvectomy to remove multiple benign lesions on the labia minora and labia majora.
7. A woman undergoes a simple vulvectomy to treat an extensive premalignant condition affecting the entire vulva.
8. A partial vulvectomy is performed on a patient with numerous benign growths on the labia majora and surrounding tissues.
9. A simple vulvectomy is performed to remove a premalignant lesion on the clitoris and surrounding tissues.
10. A physician performs a partial vulvectomy to treat an extensive benign condition affecting the labia minora and labia majora.