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Question: I'm struggling with how to code this procedure:

From the op note:

2x1 cm mass on right labia majus ...a scalpel was used to make a small 5 mm incision in the middle of the mass and the neurofibroma was slowly removed through the incision with the scalpel. When the mass was found to be completely removed, the subcutaneous layer was first re-approximated in an interrupted fashion using 2-0 vicryl. The skin layer was then re-approximated in a running fashion with 2-0 vicryl.

I know this is an incision and removal, but what should I report? Is this a neurofibroma of the labia? Path report has not come back in yet.

Kansas Subscriber

Answer: First, a neurofibroma of the labia is possible, but is very rare. A neurofibroma is not malignant and when located on the labia, the removal would be considered the removal of a benign lesion.

You should be looking at 11422 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm). Because the ob-gyn did a layered closure, you can also bill 12041 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less).

However, you should not bill code +64778 (Excision of neuroma; digital nerve, each additional digit (List separately in addition to code for primary procedure)), as the tumor was not found on the nerve. Also, code 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated) would not be correct either, as this code relates to a foreign body removal 鈥� not a lesion removal.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor