Modifier 52: Appropriate Use
Modifier 52: Reduced Services
Modifier 52 is used to describe circumstances in which services provided were reduced in comparison to the full description of the service. CPT Appendix A for modifier 52 states, ‘Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced.’
In other words, modifier 52 applies when the provider chooses to cancel a service prior to completion or to provide a reduced service. For instance, if the provider plans all along to provide a ‘lesser’ procedure or service, which no other CPT® code better describes, modifier 52 applies. Similarly, you would call on modifier 52 if the provider electively cancels a procedure or service prior to completion.
- Indicate statement ‘reduced services’ in Item 19 in CMS-1500 claim form (or electronic equivalent)
- Include brief reason for reduction
- Documentation includes complete reduction reason retained in patient’s record
- Beginning January 1, 2008, 50 percent payment reduction is applied for discontinued radiology procedures and other procedures that do not require anesthesia
- Facilities use this modifier to indicate discontinuance of these applicable procedures
- Continue to use modifiers 73 and 74 for all other types of procedures
- To determine charge amount, reduce normal fee by percentage of service not provided
- E.g., if 75% of normal service provided, reduce amount billed by 25%
- Medicare claims processing system reimburses lower of actual charge or fee schedule allowance
Guidelines for Claim Submission
- Submit the reason for the reduced service in the electronic documentation field (or, if you are approved to submit paper claims, in Item 19).
- Check the CPT code requirements. For example, many ophthalmology codes are unilateral and/or bilateral. Submitting CPT modifier 52 with one of these codes will result in an incorrect payment.
- Make sure you are submitting the correct modifier. If a procedure is a failed operative procedure or a reduced operative procedure after induction of anesthesia and after the start of the operative procedure, there are more appropriate modifiers to indicate cancelled or discontinued procedures.
- Ambulatory Surgery Centers (ASCs): refer to CPT modifiers 73 and 74.
- Physician claims for services performed in ASCs: refer to CPT modifier 53.
When Not to Use Modifier 52
- The code description includes unilateral or bilateral.
- An existing CPT or HCPCS code properly identifies the reduced service.
- Anesthesia administration and/or the patient’s wellbeing at risk were factors in ending the procedure.
Examples of Modifier 52
A surgeon performs a laparoscopic procedure for removal of bilateral pelvic lymph glands. The full description of the procedure includes “total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple.” However, the surgeon removes all except the internal iliac nodes. As the doctor elected to stop short of removing the internal iliac nodes, appending modifier 52 alerts to the reduction in services for this procedure.
A cardiologist attempted to perform a Percutaneous Transluminal pulmonary artery balloon angioplasty of the totally occluded blood vessel. The surgeon could not complete the procedure because of an anatomical problem which prevented him from performing the catheterization. Hence CPT 92997 with modifier 52 should be coded.
A patient is set to undergo a two-view chest x-ray, but only one image is obtained. In this case, report code 71010 (radiologic examination, chest; single view, frontal) instead of 71020 (radiologic examination, chest, two views, frontal and lateral) with modifier 52.
Modifiers © Copyright 2021 American Medical Association
If you’re appending modifier 52 to a claim, remember to maintain documentation explaining why the procedure was cut short. The documentation should provide plenty of detail to allow the payer to make a reimbursement decision. Still, confused about modifer 52? Don’t worry E2E Medical Billing Services has an experienced coding team that uses exact modifiers to avoid denials. To know more about our medical billing services call us at 888-552-1290 or write to us at [email protected]