General Surgery Coding Alert

Question: Our surgeon performed a salivary gland biopsy from the left and right. What code should I use, and should I report modifier 50?

Ohio Subscriber

Answer: You don’t provide enough information to choose a definitive code. CPT® provides two salivary gland biopsy codes, as follows: 

• 42400 — Biopsy of salivary gland; needle
• 42405 — … incisional.

You should use 42400 if your surgeon inserts a large, hollow-bore percutaneous needle (such as Tru-Cut or Menghini) into the salivary gland and obtains small tissue fragments for the purpose of a biopsy. On the other hand, choose 42405 if the surgeon makes an incision over a salivary gland and takes out some tissue from the gland to submit for examination.

Modifier 50 (Bilateral procedure) is not appropriate for either of these codes, even if the surgeon takes biopsies from a left and right salivary gland.

Here’s why: You can report modifier 50 only for bilateral organs such as kidney, breast, iliac crest, lungs, ovaries, vas deferens, etc. Although salivary glands occur on the right and left, there are more than two. In fact, there are three major pairs of salivary glands: the submandibular, the parotid, and the sublingual glands. 

Do this: To indicate that the surgeon biopsied two separate salivary glands, you might use a modifier such as 59 (Distinct procedural service), or if your payer prefers, a modifier such as 76 (Repeat procedure or service by same physician or other qualified health care professional).