2025 CPT code 56620
Effective Date: N/A Surgery - Surgical Procedures on the Female Genital System Surgery Feed
Simple partial vulvectomy: This procedure involves the removal of less than 80% of vulvar skin and superficial subcutaneous tissues for benign or premalignant conditions.
Modifiers may be applicable. Refer to current CPT guidelines.
Medical necessity for a simple partial vulvectomy must be established by documenting the presence of a benign or premalignant condition affecting the vulva that requires surgical removal and cannot be adequately treated with less invasive methods like local excision. The extent of the vulvectomy should be justified based on the size and distribution of the lesions.
The physician performs the surgical removal of the specified vulvar tissue, controls bleeding, closes the surgical site, and may apply a skin graft if necessary.
In simple words: A simple partial vulvectomy is a surgery to remove a part (less than 80%) of the vulva, the external female genitalia. This is done when there are widespread non-cancerous or pre-cancerous conditions. The surgery involves removing the affected skin, mucous membrane, and some underlying tissue. A skin graft might be needed if a large area is removed.
A simple partial vulvectomy involves the excision of a portion of the vulva (less than 80%), including the skin, mucous membrane, and superficial fat and connective tissue. The procedure is typically performed for benign or premalignant conditions that are extensive or numerous and not amenable to local excision. After general or regional anesthesia and placement in the dorsal lithotomy position, the affected area is marked, an incision is made, and the diseased tissue is removed. Bleeding is controlled, and the defect is closed with sutures, potentially using a skin graft for larger areas.A skinning vulvectomy, involving only the surface skin removal, is also reported with 56620 if less than 80% of the vulva is removed.
Example 1: A patient presents with extensive vulvar dysplasia affecting less than 80% of the vulvar area. A simple partial vulvectomy (56620) is performed to remove the diseased tissue., A patient has multifocal vulvar intraepithelial neoplasia (VIN) covering a portion of the left labia. A simple partial vulvectomy is performed to excise the VIN lesions., A patient is diagnosed with Paget's disease of the vulva localized to the right labia majora.A simple partial vulvectomy is performed to remove the affected area.
Documentation should include details of the size and location of the lesion(s), the extent of the vulvectomy (percentage of vulva removed), the method of closure (primary closure or skin graft), and any associated procedures like lymph node biopsy. Operative notes and pathology reports should also be included.
** It is crucial to accurately document the percentage of the vulva removed to distinguish between partial and complete vulvectomy codes.If a skin graft is performed, ensure it is coded separately with the appropriate code from the 14xxx-15xxx series. For harvesting and grafting from a separate site, code both the harvesting and grafting procedures. Review payer policies for coverage of vulvectomy for labial hypertrophy.
- Revenue Code: P1G
- Specialties:Gynecology, Gynecologic Oncology, Plastic Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient Department, Office