Vulva, Perineum, and Introitus

In the vulva, perineum, and introitus subsection, the coder should note the
definitions for
simple, radical, partial, and complete as they apply to vulvectomy (excision of the
vulva). For
vulvectomy (56620-56640), the documentation should state whether the procedure was
simple
or radical and partial or complete, and should include any additional procedure(s)
performed.
For destruction of vulva lesions, the physician should document whether simple or
extensive
destruction was performed for correct code assignment. The appropriate code is
reported only
once, regardless of the number of lesions removed. To report excision or
fulguration of urethral

I caruncle, Skene's gland cyst, or abscess, the coder should refer to codes 53265
and 53270 in
the urinary system subsection.

Vagina

The coder should read the code descriptions carefully in the vagina subsection
because some
codes include procedures that may be found in the urinary system subsection of the
CPT
code book. For example, when a sling operation for stress incontinence is performed
via
laparoscopy, code 51992 should be used from the urinary system section, not code
57288.

The appropriate code assignment for excision of the vagina (57106-57135) is

determined
by the extent of the excision and additional procedures performed. To assign code
57410, the
documentation must state that the pelvic examination was performed under
anesthesia.

In general, when the CPT description states "with or without" another procedure, it
is
included in the procedure and not reported separately. For example, the description
for code
57240 reads "anterior colporrhaphy, repair of cystocele with or without repair of
urethrocele,
including cystourethroscopy, when performed." In this case, the repair of the
urethrocele and
the cystourethroscopy would be included when performed with an anterior
colporrhaphy and

hould not be reported separately.

Placement of a suprapubic catheter is not included in GYN procedures but is

frequently per
formed. When documented, catheter placement should be reported separately as CPT
code 51102.

Cervix Uteri
In the cervix uteri subsection, the coder should refer to codes 57520-57522 for
conization of
the cervix. Conization is the removal of a cone-shaped portion of tissue. This
procedure can
be performed by cold knife or laser (57520) or through loop electrode excision
(57522). When
tissue is removed by loop electrode excision, the documentation should be reviewed
carefully
to ensure use of the correct code (57460 versus 57522). Conization of the cervix
codes include
fulguration, dilatation and curettage, and repair, when performed.

For colposcopy/vaginoscopy, the coder should refer to codes 57452-57461. This

procedure
is the examination of the cervix and/or vagina using a magnifying scope inserted
through the
vagina. The loop electrosurgical excision procedure, code 57460, is commonly
referred to as
the LEEP or LOOP procedure. The procedure involves the excision of tissue from the
cervix
with a loop electrosurgical device under colposcopic magnification. It is important
to differen
tiate 57460 from 57522, LEEP without the use of the colposcopy/vaginoscopy.

Corpus Uteri

For the corpus uteri subsection, code 58120 is used to report a dilation and
curettage (D&C),
diagnostic and/or therapeutic. This code description states "nonobstetrical" and
should not be