CPT Code 56440 Incision Procedures on the Vulva, Perineum, and Introitus

Gynecological billing requires precise coding for surgical procedures. CPT code 56440 is used explicitly for the marsupialization of a Bartholin's gland cyst, a procedure that provides a long-term solution to this common condition. Due to the procedure's specific nature and complexity, accurate coding and documentation are essential for timely reimbursement.

In this article, we'll explain the code's description, scenarios where it is applicable, relevant modifiers, and critical billing and reimbursement guidelines, all aligned with the latest 2025 AAPC updates, to help you submit accurate claims and receive timely payment.

CPT Code 56440 - Description

The official definition of CPT code 56440 is: "Marsupialization of Bartholin's gland cyst."

This code describes a surgical procedure used to treat a fluid-filled Bartholin's gland cyst, which occurs when the duct of the gland becomes blocked. Marsupialization is a technique where the surgeon makes an incision into the cyst, drains the fluid, and then stitches the edges of the cyst's lining to the surrounding skin. This creates a permanent, small pouch that allows the gland to drain continuously, preventing future fluid buildup.

This procedure is typically performed in an office or outpatient setting. It is considered a more definitive treatment than a simple incision and drainage (CPT 56420), as it is designed to prevent recurrence.

Scenarios Where CPT Code 56440 is Applicable

You would bill CPT code 56440 in the following situations:

• Definitive Treatment of a Bartholin's Cyst: When a patient has a symptomatic, non-infected Bartholin's cyst that is causing pain or discomfort.
  • Example: A patient has a chronic, large Bartholin's cyst that has recurred multiple times despite a previous incision and drainage. The physician performs a marsupialization to provide a more permanent solution.
• Treatment of a Recurrent Abscess: After a Bartholin's abscess has been treated, a marsupialization may be performed in a separate session to prevent a future recurrence.

Applicable Modifiers for CPT Code 56440

The following modifiers may be used with CPT code 56440 when needed:

• Modifier 25 indicates that a significant, separately identifiable evaluation and management (E/M) service was performed on the same day as the procedure. This is used if the provider addressed a separate issue during the visit.
• Modifier 54 specifies that the surgeon performed the surgical procedure only, and a different provider will handle the patient's postoperative care.
• Modifier 55 indicates that the physician only provided the postoperative management.
• Modifier 59 identifies a distinct procedural service. It would be used if another procedure was performed in a different anatomical area on the same day, to prevent billing denials for duplicate services.

CPT Code 56440 - Billing & Reimbursement 

To ensure proper reimbursement for CPT code 56440, follow these key steps, which are crucial for 2025 AAPC compliance:

• Justify Medical Necessity: Your documentation must clearly describe the cyst, including its location, size, and the patient's symptoms (e.g., pain, discomfort, and the size of the cyst) that necessitated the procedure. It should specifically state that it is a Bartholin's gland cyst.
• Use Accurate ICD-10 Codes: CPT 56440 should always be paired with the correct diagnosis code. The primary diagnosis is typically:
  • N75.0 – Cyst of Bartholin's gland.
  • In cases of recurrence, the code may be paired with N75.1 (Abscess of Bartholin's gland) if a previous abscess was the root cause.
• Understand Global Period and Bundling Rules: This procedure is part of a global surgical package, which includes pre-operative and postoperative care. For in-office procedures, the global period is typically 90 days, meaning separate E&M services for related care within that period may not be billable.
• Detailed Documentation: The operative note should be thorough, detailing the location, incision, drainage, and suturing technique used for marsupialization.
• Reimbursement Scenarios: Reimbursement rates depend on the payer and the place of service (e.g., in-office vs. hospital). Always verify the payer's fee schedule and policies to understand the global period and any bundling rules that may apply.

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