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BETA v.3.0

2025 CPT code 56630

Radical partial vulvectomy.

For pelvic laparotomy, use 49000. For excision or destruction of endometriomas, open method, see 49203-49205, 58957, 58958. For paracentesis, see 49082, 49083, 49084. For secondary closure of abdominal wall evisceration or disruption, use 49900. For fulguration or excision of lesions, laparoscopic approach, use 58662. For chemotherapy, see 96401-96549.

Modifiers may be applicable. Modifier 22 (Increased Procedural Services) may be used if the procedure is significantly more complex than usual. Modifier 51 (Multiple Procedures) is used if other procedures are performed at the same time.

Medical necessity for 56630 is established by the presence of vulvar malignancy or premalignant disease requiring surgical removal. The extent of resection is dictated by the size and location of the tumor and the need for negative margins.

The physician marks the area to be excised, makes an oval-shaped incision around the diseased portion of the vulva, and removes all of the skin, deep fascia, and muscle in the affected area down to the bone.Bleeding is controlled, and the wound is closed with sutures or a skin graft.

In simple words: This is a surgical procedure to remove part of the vulva (external female genitalia) because of cancer.The surgery aims to remove all the cancerous tissue plus some healthy tissue around it to reduce the risk of the cancer returning. Sometimes, a skin graft is needed to cover the area where tissue was removed.

The radical partial vulvectomy includes removal of the affected vulvar tissue. The surgery may also include removing the deep fascia of the thigh next to the vulva, part of the lower abdominal area adjacent to the vulva, and/or the perineal area below the vulva to ensure that adequate margins of non-cancerous tissue have been removed. For skin graft, if used, see 15004-15005, 15120, 15121, 15240, 15241.

Example 1: A patient with stage I vulvar cancer confined to the left side of the vulva undergoes a radical partial vulvectomy, including removal of the left labia majora, minora, and clitoris., A patient with a 3 cm vulvar squamous cell carcinoma on the perineum undergoes a radical partial vulvectomy, including removal of the perineal skin and underlying tissues., A patient with multifocal vulvar intraepithelial neoplasia (VIN) 3, a precancerous condition, undergoes a radical partial vulvectomy to remove the areas of VIN 3 with clear margins.

Documentation should include the size and location of the lesion, the extent of resection, including margins, the type of closure (primary or with graft), and any complications.

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