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."