How To Use CPT Code 56625

CPT 56625 describes a surgical procedure that involves the removal of all or part of the vulva for extensive or numerous benign or premalignant conditions. 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 56625?

CPT 56625 is a code used to describe a surgical procedure that involves the removal of the vulva for extensive or numerous benign or premalignant conditions. This procedure is performed when the removal of the affected area cannot be accomplished by local excision of a discrete lesion. It is important to note that this code does not include the use of a skin graft, which is reported separately using codes 15002 and onwards.

2. Official Description

The official description of CPT code 56625 is: ‘Vulvectomy simple; complete.’ This code represents the complete removal of the vulva, including the skin, mucous membrane, and superficial fat and connective tissue. It is important to note that if a skin graft is used to replace the removed skin, a separate code should be reported.

3. Procedure

1. The patient is placed in the dorsal lithotomy position, with knees bent and positioned above the hips, 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 diseased portion of the vulva.
4. The physician removes the affected skin, mucous membrane, and any superficial fat and connective tissue.
5. The physician securely ties the pudendal vessels and controls bleeding using electrocautery.
6. If necessary, the physician may place packing in the vagina.
7. The defect is closed using synthetic absorbable sutures.
8. If the area cannot be closed with sutures alone, the physician may use a skin graft to replace the removed skin.

4. Qualifying circumstances

CPT 56625 is performed for extensive or numerous benign or premalignant conditions of the vulva that cannot be removed by local excision of a discrete lesion. The procedure involves the removal of 80% or more of the vulva, including the skin, mucous membrane, and superficial fat and connective tissue. The clitoris may be spared unless clinically involved in the disease. This procedure is typically performed by a physician and requires the use of a general anesthetic.

5. When to use CPT code 56625

CPT code 56625 should be used when a complete vulvectomy is performed for extensive or numerous benign or premalignant conditions of the vulva. It is important to note that this code does not include the use of a skin graft, which should be reported separately using the appropriate graft codes.

6. Documentation requirements

To support a claim for CPT code 56625, the following documentation is required:

• Documentation of the patient’s diagnosis and the need for a complete vulvectomy
• Description of the surgical procedure performed, including the extent of the vulva removed
• Date of the procedure
• Details of any additional procedures performed, such as the use of a skin graft
• Any complications or unexpected findings during the procedure
• Signature of the performing physician

7. Billing guidelines

When billing for CPT code 56625, ensure that the procedure meets the criteria for a complete vulvectomy for extensive or numerous benign or premalignant conditions. It is important to note that the use of a skin graft should be reported separately using the appropriate graft codes. Additionally, it is important to follow any specific billing guidelines provided by the payer or coding guidelines.

8. Historical information

CPT code 56625 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 physician performs a complete vulvectomy on a patient with extensive vulvar dysplasia.
2. A surgeon removes 90% of the vulva for the treatment of a premalignant condition in a patient.
3. A gynecologist performs a complete vulvectomy on a patient with multiple benign lesions on the vulva.
4. A physician removes 80% of the vulva for the treatment of a premalignant condition in a patient.
5. A surgeon performs a complete vulvectomy on a patient with extensive vulvar lichen sclerosus.
6. A gynecologist removes 85% of the vulva for the treatment of a premalignant condition in a patient.
7. A physician performs a complete vulvectomy on a patient with extensive vulvar intraepithelial neoplasia.
8. A surgeon removes 95% of the vulva for the treatment of a premalignant condition in a patient.
9. A gynecologist performs a complete vulvectomy on a patient with multiple benign lesions on the vulva.
10. A physician removes 80% of the vulva for the treatment of a premalignant condition in a patient.