Labiaplasty CPT Code (2022) Description, Guidelines, Reimbursement, Modifiers & Examples

Labiaplasty CPT code 56620 bills for service when the Physician performs labiaplasty or simple partial Vulvectomy. The Physician performs surgery to remove all or part of the external components of a woman’s genitals, such as precancerous or cancerous tissue.

Labiaplasty CPT Code Description

The Physician performs labiaplasty to lower or augment the size of the patient’s labia. This procedure aims to enhance the appearance of labia or reduce physical discomfort.

The following are the reasons why the Physician performs labiaplasty:

To lower the size of labia minora to avoid the superimposition of labia majora.

To boost hygiene and health.

To improve comfort, confidence, and sexual well-being.

To increase self-confidence and eliminate visual lines.

To reduce unevenness of the labia minora or labia majora.

To rebuild a more youthful look after childbirth or aging.

The Physician eliminates part or all of the vulva to treat premalignant or malignant lesions. A simple complete vulvectomy includes removing all labia majora, labia minora, and clitoris.

In contrast, a simple, partial vulvectomy may consist of removing part or all of the labia minora or labia majora on one side and the clitoris.

The Physician explores the lower genital tract and the perianal skin through a colposcope. In Labiaplasty CPT code 56620, a wide semi-elliptical incision contains the diseased area. 

The Physician removes the underlying subcutaneous fatty tissue and a substantial portion of excised skin. Vessels clamp and tied off with sutures or are electro-coagulated to control bleeding. The significant defect is usually closed in layers using separately reportable plastic techniques. Vaginal gauze packing incorporates in the vagina.

CPT 56620 bills for service when the Physician performs Labiaplasty or simple partial Vulvectomy.

Labiaplasty CPT Code Reimbursement  

A maximum of one unit can be a bill on the same service date of Labiaplasty CPT code 56620. In contrast, the Two units allow documentation supporting the service’s medical necessity. 

The cost and RUVS of Labiaplasty CPT code 56620 are $660.97 and 19.09962 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 56620 are $660.97 and 19.09962 when performed in the non-facility. 

Labiaplasty CPT Code Modifiers 

The following are the list modifiers applicable with Labiaplasty CPT code 56620 :   

• 22, 23, 47, 51, 52, 53, 54, 55, 56, 58, 59, 62, 63, 76, 77, 78, 79, 80, 81 82, 99, , AS, CC, CR, ET, EY, GA, GC, GK, GR, GU, GY, GZ, KX, Q5, Q6, QJ, SG, TC, XR, XP, XU, XS, AI, AQ, AR.     

Modifier 47 is applicable Labiaplasty CPT code 56620  when the surgeon administers general or regional anesthesia to the patient. It is not appropriate to report modifier 47 with anesthesia procedures.  

Modifier 76 is appropriate with CPT 56620 when a similar service performs by the Same Physician on the same service date.   

Modifier 54 is applicable with CPT 56620 when the Physician provides surgical care only. In contrast, Modifiers 55 and 56 attach to CPT 56620 when the Physician performs post-management and pre-operative care only.   

Modifier 76 is applicable with Labiaplasty CPT code 56620 when a similar service performs by a different Physician on the same service date.   

Modifier 59 is applicable with CPT 56620  when a Distinct service performs by the Physician and bundles with another procedure on the same date.     

 Modifier X {E, P, S, U} is applicable instead of Modifier 59 with CPT 56620   when service bills to Medicare insurance. It divides the modifier into four parts for further specification of the procedure.   

Modifier 53 will be reported with CPT 56620 if an unsuccessful attempt for an inguinal hernia repair makes due to unavoidable circumstances like allergic reactions to the substance.   

Modifier 22 applies to CPT 56620 when services perform longer than usual and take extra resources during the procedure.   

Modifier 23 is applicable with Labiaplasty CPT code 56620 when general or local anesthesia administers by the Physician and routinely does not require during the procedure.   

Modifier 52 applies when the Physician does not complete the inguinal hernia repair service and terminates due to unavoidable circumstances.   

If physicians believe that Medicare will deny such service, reporting with a GA modifier is appropriate. The beneficiary must sign an Advance Beneficiary Notification (ABN), and CPT 56620 must apply the GA modifier to that service.

Labiaplasty CPT Code Billing Guidelines 

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate. 

The following are the most used payable dx codes for Labiaplasty CPT code 56620:

C51.0, C51.1, C51.2, C51.8, C51.9, C79.82, D07.1. D28.0, D39.8, D49.59, N90.0, N90.1, N90.3, N90.4

CPT 56620 includes removal; if the Physician removes the area Greater than 80% vulvar area, it will be the complete procedure.

If the Physician removes the less than 80% vulvar area, it will be a partial procedure.

If the Physician removes skin and deep subcutaneous tissue,  it will be a radical procedure.

If the Physician removes skin and superficial subcutaneous tissues, it will be a simple procedure.

If a Skin graft (15004-15005, 15120-15121, 15240-15241) performs in combination with Labiaplasty CPT code 56620, It is appropriate to report skin grafts separately.

CPT code 56620 has 90 days global period. If any Evaluation and management (E/M) service perform in conjunction with CPT code 56620, modifier 24 will report with E/M service for an unrelated condition. 

 Suppose the E/M visit is for postoperative care of a prior surgical procedure if the patient sees for an unrelated condition on the exact procedure date. In that case, it is not appropriate to report the E/M code with 56620 separately during the global period time. While modifier 25 will be applicable with CPT code 56620. 

Labiaplasty CPT Code Examples

The following is the example when Labiaplasty CPT code 56620 bills:

Example 1

Pre-Operative Diagnosis: Urinary Tract Infection (UTI)

Postoperative Diagnosis: same

Procedure: Labiaplasty

Physician: XYZ, MD

Anesthesia: General

Complications: None

Disposition:

The Physician discusses the risks, benefits, indications, and alternatives with the patient and signs informed consent. The patient was then taken to the procedure room and prepped and draped in the usual sterile fashion.

The labia and clitoris were then marked to the patient’s specifications using the marking pen.

The perineal area infiltrates first with the creation of a small bleb, followed by infiltration of the labia majora up to the clitoris on the left side.

The same technique utilizes on the right side.

The labia minora then infiltrates along the lines of demarcation. They then clamped using Heaney clamps, and the tissue excises. The clamped tissue cauterizes using a single tip Bovie. Excellent hemostasis was confirmed.

The exposed tissue of the clitoral hood and labia were re-approximated using 3-0 Monoderm. The clitoral hood trims using scissors. Excellent hemostasis notes.

The patient tolerated the procedure well and completed it successfully.

Example 2

A thirty-year-old female presents with pain during sexual intercourse. The patient developed an infection and took some medication for pain. 

The physical exam revealed swelling in the female genital organs. The Physician ordered an X-ray of the pelvis.

 It shows skin infections around the female genital organs. The patient denies any other symptoms such as headache, numbness, urinary problems, nausea, vomiting, and shortness of breath. 

The Physician advises labiaplasty to prevent infection in the future and prescribes mediation.

Example 3

A 25-year-old female presents with uneven labia minora and Majora. The patient did not have any other symptoms and itching in the female genital area. 

The physical exam revealed swelling in the female genital organs. The Physician ordered an X-ray of the pelvis.

 It shows no skin infections around the female genital organs. The patient denies any other symptoms such as headache, numbness, urinary problems, nausea, vomiting, and shortness of breath. 

The Physician advises labiaplasty to prevent infection in the future and prescribes mediation. The insurance may not reimburse the reason for this encounter as a cosmetic reason because the patient did not have any complaints.

Example 4

A 27-year-old female presents with a lining in the female genital area. The patient did not have any other symptoms and itching in the female genital area. 

The physical exam revealed swelling in the female genital organs. The Physician ordered an X-ray of the pelvis.

 It shows no skin infections around the female genital organs. The patient also has no skin allergies. The patient denies any other symptoms such as headache, numbness, urinary problems, nausea, vomiting, and shortness of breath. 

The Physician advises labiaplasty to prevent infection in the future and prescribes mediation. The insurance may not reimburse the reason for this encounter as a cosmetic reason because the patient did not have any complaints.

Example 5

A 29-year-old female presents with itching in the female genital area and has pain. The patient gets an infection in the genital area due to an increased size of the labia majora.

The physical exam revealed swelling in the female genital organs. The Physician ordered an X-ray of the pelvis.

 It shows no skin infections around the female genital organs. It has no dry skin allergies patient denies any other symptoms such as headache, numbness, urinary problems, nausea, vomiting, and shortness of breath. 

The Physician advises labiaplasty to prevent infection in the future and prescribes mediation. The insurance may not reimburse the reason for this encounter as a cosmetic reason because the patient did not have any complaints.