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The procedure described by CPT® Code 56631 refers to a radical partial vulvectomy combined with unilateral inguinofemoral lymphadenectomy. The vulva encompasses various structures of the external female genitalia, including the mons pubis, labia majora and minora, clitoris, vaginal vestibule, urethral opening, and vaginal opening. A radical vulvectomy is a surgical intervention primarily indicated for the treatment of invasive carcinoma affecting the vulva. This procedure is distinct from a simple vulvectomy, as it involves a more extensive excision that penetrates into the perineal fascia. In cases where malignancy is localized to a specific area of the vulva, only the affected portion is excised, as seen in codes 56630 and 56632. The surgical approach is tailored based on the disease's location and extent, ensuring that excision margins are adequately marked to include healthy tissue surrounding the malignancy. The surgical technique involves making an incision through the skin down to the subcutaneous fat, followed by deep dissection that may extend to the perineal fascia and potentially into the periosteum of the pubic symphysis, depending on the tumor's involvement. The excised tissue may include various structures based on the specific area affected, such as the labia, vaginal vestibule, and associated glands. The procedure may also involve unilateral or bilateral inguinofemoral lymphadenectomy, which is performed to remove lymph nodes that may harbor cancer cells, typically on the side of the malignancy. If the cancer is centrally located, a bilateral lymphadenectomy is warranted. The lymphadenectomy is generally performed prior to the vulvectomy, with a careful incision made to access and remove the inguinofemoral lymph nodes.
© Copyright 2025 Coding Ahead. All rights reserved.
The radical partial vulvectomy with unilateral inguinofemoral lymphadenectomy is indicated for the treatment of invasive carcinoma of the vulva. This procedure is typically performed when malignancy is present in the vulvar region, necessitating the removal of affected tissue to prevent further spread of cancer. Specific indications include:
The procedure for radical partial vulvectomy with unilateral inguinofemoral lymphadenectomy involves several critical steps, which are detailed as follows:
Post-procedure care following a radical partial vulvectomy with unilateral inguinofemoral lymphadenectomy includes monitoring for complications such as infection, bleeding, and wound healing issues. Patients may experience pain and discomfort, which can be managed with appropriate analgesics. Follow-up appointments are essential to assess recovery and to monitor for any signs of cancer recurrence. Patients are also advised on wound care and activity restrictions to promote healing. Additionally, lymphatic drainage issues may arise due to lymphadenectomy, and patients may require education on managing potential lymphedema.
| Short Descr | VLVCTMY RAD PRTL UNI LYMPHAD | Medium Descr | VULVECTOMY RAD PRTL UNI INGUINOFEM LMPHADECTOMY | Long Descr | Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 2 - Co-surgeons permitted and no documentation required if the two- specialty requirement is met. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 132 - Other OR therapeutic procedures, female organs |
This is a primary code that can be used with these additional add-on codes.
| 38900 | Addon Code MPFS Status: Active Code APC N ASC N1 Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure) |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2025-01-01 | Changed | Short Description changed. |
| 2013-01-01 | Changed | Medium Descriptor changed. |
| 1993-01-01 | Added | First appearance in code book in 1993. |
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