Modifier 52

Modifier 52 (2022) Description, Uses, Guidelines & Examples

Modifier 52 appends to the service when the physician reduces the service due to unavoidable circumstances. 

Modifier 52 Description

Modifier 52 is applicable when the service reduces or is partially performed by the physician or other skilled professional due to unavoidable circumstances. It usually indicates the service which reduces due to cause along with other procedure codes and services. It may not affect the original procedure, and insurance pays for the percent of work performed by the physician. 

Modifier 52 is inappropriate to report when the hospital outpatient bill the service that was partially reduced or canceled due to extenuating circumstances or life-threatening condition of the patient before or after the administration of anesthesia. Reporting with modifiers 73 and 74 for ASC hospital outpatient use is appropriate. 

Modifier 52 is not applicable for the evaluation and management service as it may be adequate to bill with diagnostic and surgical procedure codes. The diagnostic and procedure may bill with modifier 52 when anesthesia does not plan for the patient.

The service may discontinue by the surgeon or other skilled professional after the preparation of the procedure in the operating room where the service should furnish by the provider. 

Modifier 52 is applicable for radiological procedure codes when no other CPT codes exist for that service and service reduces by the physician. 

For Instance, The radiologist plays to perform the two views of chest Xray but can achieve one picture of the chest X-ray. It is inappropriate to report modifier 52 with CPT 71046 as one view CPT code 71045 exists for the service. 

CPT code 77067 bills for the service when the physician performs bilateral mammographic screening. The physician only performs screening on the unilateral breast because of left breast mastectomy. No other CPT code exists for unilateral screening, and it is appropriate to report with modifier 52. 

52 modifier

What Is Modifier 52?

Modifier 52 applies to services when the physician reduces or partially performs the service due to inevitable circumstances. The physician may not plan to repeat this service in the future.

When To Use Modifier 52

Modifier 52 is used for the service when the physician reduces or eliminates the service or procedure due to inevitable circumstances.

Modifier 52 is appropriate to report radiological procedures or services that may not require the administration of anesthesia.

Modifier 52 Guidelines

The following are the guidelines when modifier 52 is appropriate: 

Documentation must support the medical necessity of the service and be medically necessary to append modifier 52.

Modifier 52 is inappropriate to report to Ambulatory Surgical Center (ASC) and adequate to bill with modifiers 73 and 74 for discontinued procedures.

Modifier 52 is inapplicable when the physician or other skilled professional when the procedure discontinues after the administration of anesthesia. It is appropriate to report with modifier 53.

Modifier 52 is irrelevant when the physician or other skilled professional performs the evaluation and service (99201-99499). It is appropriate to report with E/M modifiers such as 24, 25, 57, etc. 

The surgical procedure requires appropriate documentation, an operative report, and a concise statement when submitted with modifier 52 for reduced services. This information must indicate in the CMS 1500 form under block 19 or maybe encircled, underlined, or highlighted in the operative report or the electronic medical record. 

If the medical claim submits to the insurance without proper or complete documentation, a separate concise statement, the insurance or third-party payer may reject the claim as “unprocessable.”

Electronic documentation may submit through the Palmetto GBA eServices portal or with the Claims Processing PWK Fax Cover Sheet process. In contrast, the Paper claim sends with CMS 1500 form, including an attachment.

Modifier 52 frequently bills with radiology CPT due to multiple services in the CPT code descriptor. If there is no separate CPT code available for a single procedure and the procedure code has two components.

For Instance, the physician traverses the gastrointestinal tract with barium swallowing. The patient gets to start the allergic reaction with barium and stops the procedure.

It is appropriate to report this service with modifier 52. CPT code 74230 reports with modifier 52. 

Modifier 52 Examples

The following are examples of when the modifier 52 bills with the CPT code: 

Example 1

A 12-year-old male presents to the hospital outpatient setting with a sore throat, fever, and difficulty swallowing. The patient is incapable of eating anything and has severe pain. The patient denies any headache, swelling in the lower extremity, dizziness, nausea, or vomiting. 

The physical exam reveals the swelling in the throat region and temperature. The physician orders the CT and MRI of the neck region.

 The studies show severe tonsillitis on the right side of the throat region. The physician decides to do a right-side tonsillectomy—the procedure scheduled for the patient by tomorrow.

The physician performs the unilateral tonsillectomy successfully on a twelve-year-old patient. In contrast, the procedure performs on the right side only. CPT code 42820 may report for this service which contains bilateral in the code descriptor. It is appropriate to bill CPT code 42820 with modifier 52. 

Example 2

A 51 years-old male who denies any past medical history presented to ED with Left chest/epigastric pain x 5 days on and off, primarily constant now, burning in nature, 9 out of 10, and worse on exertion.  

He cannot take any food and denies shortness of breath, diaphoresis, nausea, vomiting, cough, hemoptysis, palpitations, leg pain, or swelling: no excessive belching, flatus, diarrhea, constipation, fever, or chills. 

Physical exams revealed that pain is related to upper GI despite heart-related and differential dx were GERD, gastritis, and inflammation of upper GI. Diagnostic studies like CT and MRI of the abdomen and pelvis revealed that Upper GI is severely inflamed.

The doctor consulted with a Gerontologist and suggested doing EGD to treat the inflamed GI tract. The patient placed an appointment with a gastroenterologist for EGD. 

If the physician traverses the stomach to perform the EGD and does not examine the duodenum, there are no plans to repeat the EGD in the future. It is appropriate to report CPT code 43235 with modifier 52.

Example 3

Forty-six years old female with PMH of hypertension and a family history of heart diseases heart murmur, LBBB dx 1 year ago, migraines, tested positive for COVID 1 month ago. She presents to ED c/o constant lip-tingling, lightheadedness, and left-sided chest discomfort since yesterday afternoon. The patient did not vaccinate for COVID.

 He woke this morning with the same symptoms, developed left upper extremity and bilateral hand tingling, and denies headache, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, changes in vision, urinary complaints, or any other symptoms.

 The patient has a great family history of heart diseases. Physicians plan to do labs, EKG, Xray, CT, and chest MRIs. The studies reveal the patient needs to remove the pacemaker due to malformation. The physician schedules the appointment for the removal of the pacemaker by next week.

The physician decides to do the removal of the pacemaker via transvenous extraction. The physician starts the procedure, the patient’s condition worsens, and he starts shaking before administering anesthesia. 

The physician terminates the procedure and does not plan to repeat the service. It is appropriate to report this CPT code with modifier 52. 

Modifier 52 vs 53 

Modifier 52 is appropriate when the physician performs the service partially or reduced due to unfortunate circumstances. They do not execute all components of the CPT code for the service and eliminates by the physician.

It is inapplicable to append with unlisted procedure codes because no service description mentions in the procedure.

The service may reduce due to the absence of either surgical, accidental, or congenital body parts, such as if the patient had a history of right mastectomy and now have a procedure on the left breast. The CPT code may apply to both sides of the breasts, and no other unilateral code is present for the service.

It is appropriate to report with modifier 52. 

In contrast, Modifier 53 is appropriate when the physician terminates or discontinues the service or procedure due to extenuating circumstances for the patient’s well-being.

The extenuating service may be like the patient started severe shortness of breath or allergic reaction after getting any medication during the procedure and have a threat to the patient’s life. 

How Does Modifier 52 Affect Reimbursement?

The insurance or third-party payer may reimburse the price manually when modifier 52 adds to the CPT code. The allowed amount adjusts by the insurance according to the percentage of procedures performed by the physician.

Documentation must mention the beginning and end times of the procedure and explain the percentage of work performed along with the record of services that do not furnish due to unavoidable circumstances when adding modifier 52 to the service. The insurance may request all this information when needed.

The time should indicate in hours and minutes if the procedure is time-based. The insurance may pay for the service according to the time duration of the service.

They will pay 65% of the total allowed amount to the provider. For Instance, the physician provided 65 % percent of the service, and 35% reduced. 

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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