Patient presents for a scheduled initial resection of a primary peritoneal malignancy. The surgeon is prepared to also perform a bilateral salpingo-oophorectomy and omentectomy to ensure complete removal of the malignant growth. During the procedure, the surgeon determines that only the left fallopian tube and ovary needs to be removed. CPT code 58950, Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy, should be reported:

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The procedure was less extensive than planned, as only the left fallopian tube and ovary were removed instead of both sides. Therefore, modifier -52 (reduced services) should be used to indicate that the full bilateral procedure was not performed.

Patient Presents for a Scheduled Initial Resection of a Primary