How To Use CPT Code 56630

CPT 56630 describes a surgical procedure performed on the vulva for the removal of all or part of the vulva in cases of malignant disease. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 56630?

CPT 56630 is a code used to describe a surgical procedure performed on the vulva to remove all or part of it in cases of malignant disease. This procedure may also involve the removal of lymph nodes and the clitoris, depending on the extent of the disease. It is considered a radical surgery, as adjacent tissue to the malignancy is also removed.

2. Official Description

The official description of CPT code 56630 is: ‘Vulvectomy, radical, partial.’

3. Procedure

1. The patient is placed in the dorsal lithotomy position, with knees bent and spread apart using stirrups.
2. A general anesthetic is administered to the patient.
3. The surgeon marks the area to be excised and makes an oval-shaped incision around the diseased portion of the vulva.
4. All of the skin, deep fascia, and muscle in the affected area down to the bone are removed.
5. The pudendal vessels are securely tied to control bleeding.
6. Packing may be placed in the vagina.
7. The defect is closed with synthetic absorbable sutures.
8. If the area cannot be closed with sutures alone, a skin graft may be used to replace the removed skin.

4. Qualifying circumstances

CPT 56630 is performed in cases of malignant disease of the vulva, where all or part of the vulva needs to be removed. The extent of the surgery depends on the stage and location of the disease. The procedure may also involve the removal of lymph nodes and the clitoris. It is important to note that CPT 56630 is a radical vulvectomy where less than 80% of the vulva is removed.

5. When to use CPT code 56630

CPT code 56630 should be used when performing a radical vulvectomy to remove all or part of the vulva for malignant disease. It is important to accurately document the extent of the surgery and the specific areas of the vulva that were removed.

6. Documentation requirements

To support a claim for CPT 56630, the following documentation is required:

• Diagnosis of malignant disease of the vulva
• Extent of the vulvectomy performed (e.g., removal of top, bottom, right or left side of the vulva)
• Date of the procedure
• Details of the surgical technique used
• Any additional procedures performed (e.g., removal of lymph nodes, clitoris)
• Use of a skin graft, if applicable
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT 56630, ensure that the procedure meets the criteria for a radical vulvectomy for malignant disease. It is important to accurately document the extent of the surgery and any additional procedures performed. If a skin graft is used, the appropriate graft code should also be reported. It is important to follow the specific guidelines provided by the payer and use the appropriate modifiers, if necessary.

8. Historical information

CPT 56630 was added to the Current Procedural Terminology system on January 1, 1990. There have been several historical changes to the code, including being added and removed from the Inpatient Only (IPO) list for Medicare. It is important to stay updated with the latest coding guidelines and payer requirements.

9. Examples

1. A patient undergoes a radical partial vulvectomy to remove the top portion of the vulva affected by malignant disease.
2. A surgeon performs a radical partial vulvectomy, removing the right side of the vulva to ensure adequate margins of non-cancerous tissue.
3. In a radical partial vulvectomy, the surgeon removes the bottom portion of the vulva and also performs a lymph node dissection.
4. A patient undergoes a radical partial vulvectomy, with removal of the left side of the vulva and the clitoris.
5. A surgeon performs a radical partial vulvectomy, removing the top and bottom portions of the vulva, as well as the deep fascia of the thigh adjacent to the vulva.
6. In a radical partial vulvectomy, the surgeon removes the right side of the vulva, the clitoris, and also performs a skin graft to replace the removed tissue.
7. A patient undergoes a radical partial vulvectomy, with removal of the left side of the vulva and the deep fascia of the thigh, as well as a lymph node dissection.
8. A surgeon performs a radical partial vulvectomy, removing the bottom portion of the vulva and performing a skin graft to close the defect.
9. In a radical partial vulvectomy, the surgeon removes the top and right side of the vulva, as well as the deep fascia of the thigh and the clitoris.
10. A patient undergoes a radical partial vulvectomy, with removal of the left side of the vulva, the clitoris, and the deep fascia of the thigh, as well as a lymph node dissection.