Modifier 52

Partially Reduced or Eliminated Services

Instructions

This modifier is used to indicate partial reduction, cancellation or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. It also identifies a situation where a physician reduces or eliminates a portion of a service or procedure.

Correct Use

  • Indicate statement "reduced services" in Item 19 in CMS-1500 claim form (or electronic equivalent)
    • Include brief reason for reduction
    • Documentation includes complete reduction reason retained in patient's record
  • Beginning January 1, 2008, contractors apply a 50 percent payment reduction for discontinued radiology procedures and other procedures that do not require anesthesia
    • Facilities use this modifier to indicate discontinuance of these applicable procedures
    • Continue to use modifiers 73 and 74 for all other types of procedures
  • To determine charge amount, reduce normal fee by percentage of service not provided
    • E.g., if 75% of normal service provided, reduce amount billed by 25%
    • Medicare claims processing system reimburses lower of actual charge or fee schedule allowance

Example: Provider performs 75% of service and appends modifier 52

Description Amount
Medicare Physician Fee Schedule (MPFS) allowed amount* $100
Reduced Billed Amount ($100 x 75%) $ 75

*Medicare recognizes that many providers use one standard fee schedule for all insurance carriers. Therefore, reducing the charge amount may differ from the example.

Incorrect Use

  • Do not confuse with "terminated procedure" modifier 53
  • Inappropriate with E/M codes

Special Appeal Instructions

  • When submitting the Redetermination request
    • Separate, concise statement explaining necessity for allowable reduction
    • Submit operative report and/or chart notes

Claim Coding Example

This bilateral procedure was performed on one eye (unilateral) only. Since the code is allowed at a bilateral rate, the provider must append modifier 52 to reduce charges. In this case, it is not appropriate to use RT or LT.

Treatment Description CPT/Modifier
Fundus photography with interpretation/report; bilateral 92250 52

 

Resources

 

Last Updated Thu, 11 Apr 2019 10:41:14 +0000