Case Studies—Female Genital System Operative Report

Abstract from Documentation:

1. Review the Alphabetic Index for coding selections for vulvectomy procedures. What documentation is needed for the coding selection?

2. Note the definitions for simple, radical, partial, and complete vulvectomy codes (listed before code 56405). What documentation from this operative note leads you to the correct definition?

3. Was this a radical (removal of skin and deep subcutaneous tissue) or simple (removal of skin and superficial subcutaneous tissue) procedure?

4. Time to Code:

1. Complete, Partial, Radical, Simple

2. Physician dictates that the vulvectomy was partial (removes less than 80 percent of vulvar area).

3. The term “undermined” (dig beneath) implies that it was beyond the superficial subcutaneous tissues. It may be a good step to query the physician in this case.

4. Index:
Vulvectomy, partial (56620, 56630–56632)

Code(s):
56630 Vulvectomy, radical, partial