Lynn Posted Thu 07th of April, 2016 06:59:22 AM
What codes would you use for this?
Laser excision of vaginal lesions, wide local excision of the vulva, multiple excisional biopsies of the vulva...FINDINGS: Acetowhite change at the vaginal apex and on the left vaginal sidewall, both areas lasered. Multiple pigmented lesions on the vulva bilaterally with several appearing to be actinic keratoses, all others appeared to be small pigmented macules, all vulvar lesions were removed.
PROCEDURE: After verifying informed consent, the patient was taken to the operating room where a timeout was performed to verify the correct patient, procedure, and site. General anesthesia was administered and found to be adequate. The patient was positioned in the dorsal lithotomy position in the candy-cane stirrups. Exam under anesthesia was performed and revealed the above findings. Patient was then prepped and draped in the usual sterile fashion. A sterile bivalve speculum that was laser appropriate was placed in the vagina. The previously defined abnormal areas on the colposcopy were ablated using the carbon dioxide laser after injecting them with 0.25% Marcaine with epinephrine. At this point, attention was turned to the vulva where the larger lesion at the inferior left labia majora was excised in the wide local excision and the incision site was then lasered to achieve hemostasis and then closed with 4-0 Vicryl in a subcuticular fashion. The left labia majora superolateral lesion was also excised in a wide local excision fashion and 2 interrupted mattress sutures with 4-0 Vicryl were used to close the excision. The rest of the vulvar lesions were removed as shaved biopsies. The laser device was used throughout to obtain excellent hemostasis. Silvadene was then applied to the top of the vagina and all the vulvar lesions. The vulva was dressed with a Kerlix fluff. The patient tolerated the procedure well. Sponge, lap, instrument, and needle counts were correct x2 at the end of the procedure. The patient was taken to the recovery room in good condition.
SuperCoder Answered Fri 08th of April, 2016 02:58:04 AM
AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail email@example.com for more information.
Lynn Posted Fri 08th of April, 2016 06:57:09 AM
My doctor did laser excision of vaginal lesions, wide local excision of the vulva, multiple excisional biopsies of the vulva. I was thinking that these codes cover this 56620 57061 56515. What do you think?
SuperCoder Answered Mon 11th of April, 2016 04:44:22 AM
According to your latest post, the CPT code would be 57061 for laser excision of vaginal lesions; 56620 for wide local excision of the vulva; and 56605 + 56606 X number of lesions for multiple excisional biopsies of the vulva.
However, 56620 is bundled with 56605 and cannot be billed together in any circumstances, so you would code 56620 only.
Hence your codes would be 57061 and 56620.
Hope this helps!