If a code in the male genital subsection does not specify unilateral or bilateral, the coder should assume unilateral.

If a code in the male genital subsection does not specify unilateral or bilateral, the coder should assume unilateral.

• A. True
• B. False
• C. Only for bilateral
• D. Not specified

Answer: (A)

In CPT coding, laterality is required when the code distinguishes between unilateral and bilateral procedures. If a code in the male genital subsection does not specify right/left or bilateral, the default assumption is unilateral. This aligns with the principle that a single code generally represents one side unless the documentation or a dedicated bilateral code indicates otherwise. Therefore, if the operative report does not state bilateral involvement or a specific bilateral code, you code for one side only. If the procedure truly involved both sides, you would see explicit documentation or use a bilateral code/modifier as appropriate.

In CPT coding, laterality is required when the code distinguishes between unilateral and bilateral procedures. If a code in the male genital subsection does not specify right/left or bilateral, the default assumption is unilateral. This aligns with the principle that a single code generally represents one side unless the documentation or a dedicated bilateral code indicates otherwise. Therefore, if the operative report does not state bilateral involvement or a specific bilateral code, you code for one side only. If the procedure truly involved both sides, you would see explicit documentation or use a bilateral code/modifier as appropriate.