2025 CPT code 56625
Effective Date: N/A Surgery - Surgical Procedures on the Female Genital System Feed
Vulvectomy, simple; complete.
Modifiers may be applicable, such as 22 (Increased Procedural Services), 51 (Multiple Procedures), etc., based on specific circumstances.
Medical necessity must be supported by documentation showing that the procedure is necessary to treat a medically significant condition affecting the vulva, such as precancerous changes, severe lichen sclerosus, or other conditions where less invasive treatments are not appropriate.
The physician's responsibilities include: patient positioning (dorsal lithotomy), catheter placement, administering anesthesia, marking the excision area, performing the incision and tissue removal, controlling bleeding, closing the wound, and potentially applying a skin graft.
In simple words: A simple complete vulvectomy is a surgery to remove most of the outer female genitals (vulva) due to widespread non-cancerous or pre-cancerous conditions. The surgeon removes the affected skin and some tissue underneath.Sometimes a skin graft is needed to cover the area.
This code describes a complete simple vulvectomy, a surgical procedure where 80% or more of the vulva is removed. This includes the skin, mucous membrane, and superficial subcutaneous tissues (superficial fat and connective tissue). The clitoris may be spared if not clinically involved.The procedure typically involves marking the area to be excised, making an oval incision, removing the tissue, tying off blood vessels, controlling bleeding with electrocautery, and closing the defect with sutures. A skin graft may be necessary for larger areas.
Example 1: A patient with extensive lichen sclerosus unresponsive to topical treatment undergoes a simple complete vulvectomy., A patient with high-grade vulvar intraepithelial neoplasia (VIN) covering a large area of the vulva has a simple complete vulvectomy., A patient with multiple large, symptomatic condylomas on the vulva has a simple complete vulvectomy to remove them.
Documentation should include details about the condition necessitating the vulvectomy, size and location of lesions, extent of vulvar involvement, operative technique, closure method (sutures, graft), and any complications.
** Distinguish between simple and radical vulvectomy. Simple vulvectomy involves removal of skin and superficial subcutaneous tissues, while radical vulvectomy includes deeper structures and potentially lymph nodes.
- Revenue Code: P1G
- Specialties:Gynecology, Gynecologic Oncology
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Inpatient Hospital (if extensive or complex)