"CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.""

CPT modifier 52 Usage and Reimbursement
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.
Inappropriate Usage
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.
Reimbursement:
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%.
Please note:
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.
CMS FAQs
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."
Popular Posts
-
Modifier - as the name implies a modifier will modify a service / procedure or an item under certain circumstances for appropriate reimbur...
-
An OPPS payment status indicator is assigned to every HCPCS code. The status indicator identifies whether the service described by the H...
-
This procedure is medically necessary only when it requires the professional skills of a therapist, is designed to address specific ne...
-
Mohs surgery, also known as chemosurgery, created by a general surgeon, Dr. Frederic E. Mohs, is performed to remove complex or ill-defi...
-
Claim Adjustment Reason Codes (CARC) CO-22 or PR-22 This care may be covered by another payer per coordination of benefits. CO-19 This is...
-
Definition: The “-59” modifier is used to indicate a distinct procedural service. The physician may need to indicate that a procedure or...
-
Ambulance transportation is a covered service when the patient’s condition is such that the use of any other method of transportation would...
-
This procedure may be medically necessary for training patients whose walking abilities have been impaired by neurological, muscular, o...
-
Sentinel lymph node identification and biopsy typically involves a multidisciplinary approach. A nuclear medicine procedure called lymph...
-
AAPC’s Certified Professional Coder (CPC) credential is the gold standard for medical coding in physician office settings and held by more ...
