"CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association."
Modifier -52 identifies situations where the physician elects to reduce or eliminate a portion of a service or procedure. Cover letters or operative reports are not necessary when Modifier -52 is used since these claims are seldom sent to medical review. Physicians may find it helpful to provide the payer with an explanation of the reduced fee compared to the usual fee in a cover letter or operative report, although it may impede claims processing. The reduction in charge reflects the reduction or elimination of a portion of the service.
Do not use for terminated procedures or elective cancellation of a procedure before anesthesia induction, intravenous (IV) conscious sedation, and/or surgical preparation in the operating suite.
Do not use for situations when the patient has the inability to pay the full charge.
Do not use on a time-based code (i.e. anesthesia, psychotherapy, or critical care).
Do not report on Evaluation & Management and Consultations codes.
There are no industry standards for reimbursement of claims billed with modifier 52 from the Centers for Medicare and Medicaid Services (CMS) or other professional organizations.The reimbursement will be based on what was completed and accomplished. To determine the amount to charge, reduce the normal fee by the percentage of the service not provided. For example, if 75% of the normal service was provided, reduce the amount billed to Medicare by 25%.
Providers need not submit Medical records at the time of claim submission but need to indicate "Documentation available upon request" in item 19 or the electronic equivalent.
It is not appropriate to use modifier 52 if a portion of the intended procedure was completed and a code exists which represents the completed portion of the intended procedure.
Can we apply Modifier 52 for bilateral procedures when the provider was able to perform only one side of the procedure or service?
Yes. It is appropriate to use modifier -52, for reduced services on "bilateral" procedures, unless the specific CPT/HCPCS description contains language indicating that the test, procedure, or service is "unilateral or bilateral". For CPT/HCPCS codes that describe "unilateral or bilateral" language in their respective descriptions, use of the -52 modifier is not necessary since the test, procedure, or service can be performed and paid at the same rate for "unilateral or bilateral" services rendered."
Modifier - as the name implies these are the two digit codes that modifies a service / procedure or an item under certain circumstances. M...
Therapeutic activities are considered medically necessary for patients needing a broad range of rehabilitative techniques that involve ...
Manual therapy includes the following modalities: - Manual traction may be considered reasonable and necessary for cervical radiculopa...
Evaluation Codes (CPT Codes 97001 and 97002 for physical therapy) and (CPT Codes 97003 and 97004 for occupational therapy)The initial evaluation identifies the problem or difficulty the patient is having which helps determine the appropriate therapy necessar...
Global Period is a time frame following surgery during which routine care by the physician i.e., all necessary services normally furnished b...
Sentinel lymph node identification and biopsy typically involves a multidisciplinary approach. A nuclear medicine procedure called lymph...
Urgent Care Centers are the Facilities that delivers Outpatient Medical Care usually for the conditions that does not require Hospital a...
Mohs surgery, also known as chemosurgery, created by a general surgeon, Dr. Frederic E. Mohs, is performed to remove complex or ill-defi...
Myocardial perfusion imaging is being done to determine the significance or the extent of myocardial ischemia (or scar), or to assess my...
Orthotic(s) fitting and training, upper extremity(ies), lower extremity(ies), and/or trunk may be considered reasonable and necessary ...