A patient is admitted in a clinic after accidentally ripping her labia during sexual intercourse due to a piercing. There was a jagged 3 centimeter laceration to the left of the labia. The provider decides to perform a simple partial vulvectomy and repair of labia minora.
In addition, the provider notes the amputation of the torn labia. He also indicates that the 3 centimeter labial tear was closed “with good cosmetic effect.”
What CPT code should you report?
For the vulvectomy and labiaplasty performed by the provider, you should report 56620 Vulvectomy simple; partial. The procedure covers both the excision of the 3-centimeter labial tear and repair of the labia minora.
If you’re tempted to use a code from the integumentary system section of the CPT code book like 15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area or repair codes 12042 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm and 13132 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm. think again.
The American Medical Association (AMA) is quick to clarify that a labiaplasty is “different than just a skin/dermatologic procedure, as there are nerves, arteries and so on that must be avoided” (CPT Assistant, December 2013).
The term labiaplasty refers to a plastic surgery procedure that alters the labia minora (inner labia), labia majora (outer labia), and the folds of skin surrounding the human vulva. In this procedure, the surgeon may decide to reshape the labia, reduce the size of the inner labia or repair the area following disease, injury or childbirth.
If the surgeon performs a procedure involving removal of skin and deep subcutaneous tissue or greater than 80% of the vulvar area, you should report 56625 Vulvectomy simple; complete instead. In the case presented in this article, however, 56620 is the CPT code that fits best.
For the ICD-10-CM codes, you should report S31.41XA Laceration without foreign body of vagina and vulva for the labial tear; and X58.XXXA Exposure to other specified factors; initial encounter to document the cause of injury (laceration).