General Surgery Coding Alert

Question: A patient underwent a laparoscopic total pelvic lymph node dissection. The code 38571 represents a bilateral procedure, but in this case the surgeon only did the left side. Do I need to modify my coding?

Massachusetts Subscriber

Answer: Yes. You will need to append modifier 52 (Reduced services) to 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy) to show that your surgeon did not perform the procedure exactly as described in the code descriptor.

You should use modifier 52 when services your surgeon performs are less than those described by the code. For instance, you can use modifier 52 when the surgeon performs a service/procedure unilaterally when the code specifies "bilateral." In such a case, before appending modifier 52, you must be certain that there is no designated CPT code to describe the lesser procedure.