modifier 52

(2022) Modifier 52 – Description & Billing Guidelines

Modifier 52 Description

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 the 52 modifier 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.

Usage Of The 52 Modifier

Do not use CPT modifier 52 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 the 52 modifier for situations when the patient has the inability to pay the full charge.

Do not use modifier 52 on a time-based code (i.e. anesthesia, psychotherapy, or critical care).

Do not report on Evaluation & Management and Consultations codes.

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.

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.

Modifier 52 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 for the 52 modifier 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%.

52 Modifier FAQ

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.”

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2 Comments

  1. Am insurance is denying because the procedure is inconsistent with the modifier used. The modifier in the claim is 52 for a CPT 70551 a MRI Brain W/O Contrast. Insurance was advise that no other modifier can be used but they still deny for the same reason. Can we add another Modifier together with 52?

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