Modifier 52 denotes reduced services. A modifier indicating the basic service done during a process should be applied to the CPT code. Choosing among modifiers 53 and 52 can be challenging at times. Denials might result from using the incorrect modifier. The ambiguity in its meanings is the source of this concern.
Modifier 52: Reduced services
Modifier 52 is used to identify situations in which the services offered were scaled back compared to the complete description of the product. ‘Under certain conditions, a process is partially reduced at the physician’s discretion,’ according to CPT Appendix A for modifier 52. Under these conditions, the service supplied can be identified by its specific process number plus the modifier 52, indicating that the service is reduced.’
In other words, modifier 52 occurs when a provider decides to discontinue or offer a reduced service before to completion of a service. For example, if the provider intends to provide a ‘lesser’ treatment or service that no other CPT® code adequately represents, modifier 52 applies.
Appropriate use
- In Item 19 of the CMS-1500 claim form, including the statement reduced services.
- Include a brief explanation for the reduction.
- The documentation contains the whole reduction explanation, which is included in the patient’s record.
- Beginning January 1, 2008, a 50% payment decrease is applied to terminated radiology therapies and other non-anaesthetic procedures.
- This modification is used by facilities to signify the discontinuance of these applicable procedures.
- Modifiers 73 and 74 should be used for all other sorts of operations.
- To calculate the charge amount, divide the standard rate by the proportion of service not supplied.
- For example, if 75 per cent of standard service is supplied, reduce the price billed by 25%.
- The Medicare claims processing system pays the lesser of the actual amount or the fee schedule allowance.
Inappropriate use
- The code description includes terms such as unilateral and bilateral.
- The reduced service is correctly identified by an existing CPT or HCPCS code.
- The procedure was terminated due to anesthesia administration and compromised the patient’s well-being.
Claim submission guidelines
- Fill out the electronic health records form explaining the reduced service (or, if you are approved to submit paper claims, in Item 19).
- Examine the CPT required specifications. Many ophthalmology codes are unilateral and bilateral. If you submit CPT modifier 52 with a few principles, you will receive an invalid payment.
- Check that you’re using the correct modifier. There are more suitable modifiers to signify cancelled procedures if a process is a failed operative treatment or a curtailed operative procedure after induction of anesthesia and after the beginning of the operative system.
- CPT modifiers 73 and 74 apply to ambulatory surgery centers (ASCs).
- CPT modifier 53 should be used for physician claims for work rendered in ASCs.
Modifier 52 examples
Example 1
A surgeon performs a laparoscopic operation for removing bilateral pelvic lymph glands. The operation is described as “complete pelvic lymphadenectomy with peri-aortic lymph node sample (biopsy), single or multiple.” The surgeon, however, eliminates all but the internal iliac nodes. Because the clinician chose not to remove the internal iliac nodes, attaching modifier 52 indicates a reduction in services for this treatment.
Example 2
A cardiologist performed a Percutaneous Transluminal Pulmonary Artery Balloon Angioplasty on an utterly blocked blood vessel. The surgeon could not complete the experiment due to an anatomical issue that precluded him from conducting the catheterization. As a result, CPT 92997 with modifier 52 should be used.
Remember to keep documentation indicating why the operation was stopped short if you add modifier 52 to a claim. The paperwork should be detailed enough for the payer to establish a reimbursement determination. Still, have questions about modifier 52? Don’t worry, Billing Executives Medical Billing Services has a skilled coding team that use precise modifiers to avoid denials. To learn more about our medical billing services, please contact us at rcmexpertz@gmail.com
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