Saturday, March 6, 2010

CPT modifier - 52 - Reduced services

Modifier 52: Reduced Services Description:

Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).

This modifier has not been identified in any other rule.

* This modifier does not override an edit.
* Health Plans may apply a payment adjustment based on the modifier.

Documentation of the unusual circumstances may be required to accompany the claim (e.g., a copy of the operative report and a separate statement written by the physician explaining the unusual amount of work required). 

Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier -52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.

Use modifier 52 (reduced service) to indicate a service or procedure is partially reduced or eliminated at the physician’s election. When you report modifier 52, include office records, test results, operative notes, or hospital records to substantiate the reason for reporting a reduced service. If this information is NOT included, your claim may be denied/rejected.
Note: CMS has clarified that the 52 modifier should not be used with evaluation and management services.


Insurance guidelines.

52 Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced.

KMAP does not recognize modifier 52 when used on E&M codes if supporting documentation is not submitted to support its use.

Do not use this modifier if the procedure is discontinued after administration of anesthesia (use modifier 53).

53 Under certain circumstances, the physician can elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance can be reported by adding modifier 53 to the code reported by the physician for the discontinued procedure.

Modifier 53 should not be used on E&M codes. It is only valid for surgical and medical diagnostic codes when the procedure was started but had to be discontinued because of extenuating circumstances.

KMAP denies E&M codes when billed with modifier 53. 54 55, 56, 80, 81, 82, AS

When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical codes can be identified by adding the modifier 54. Physicians who perform the surgery and furnish all of the usual pre- and post-operative work bill for the global package by entering the appropriate CPT® KMAP uses the Medicare Physician Fee Schedule Relative Value file to determine which procedures are appropriately billed with modifier 54.

code for the surgical procedure only; therefore, modifiers 54 and 55 cannot be combined on a single detail line item. KMAP uses the Glob Days field on the file as a basis to determine proper usage of modifier 54. The following determinations have been made based on the individual indicators.

• This modifier cannot be used on procedures unless the Glob Days field is equal to 010 or 090 on the Medicare Physician Fee Schedule Relative Value file. Any procedure billed to Medicaid with modifier 54 and global surgery days other than 010 and 090 will be denied unless Medicaid has instructed differently through provider bulletins and/or manuals.

• This modifier can only be used on procedures which have a Glob Days field equal to 010 or 090 on the Medicare Physician Fee Schedule Relative Value file. Any procedure billed to Medicaid and assigned global surgery days equal to 010 or 090 will process as normal.

Complete definitions of the Glob Days indicators are available on the CMS website. Once within the document, perform a word search for MPFSDB Record Layouts and look for the particular year in question (such as 2008, 2009).

55 54, 56, 78, 80, 81, 82, AS When one physician performs the postoperative management and another physician performs the surgical procedure, the postoperative component can be identified by adding modifier 55 to the code. Physicians who perform the surgery and furnish all of the usual pre- and post-operative work bill for the global package by entering the appropriate CPT®

• This modifier cannot be used on procedures unless the Glob Days field is equal to 010 or 090 on the Medicare Physician Fee Schedule Relative Value file. Any procedure billed to Medicaid with modifier 55 and global surgery days other than 010 and 090 will be denied unless Medicaid has instructed differently through provider bulletins and/or manuals.

code for the surgical procedure only; therefore, modifiers 54 and 55 cannot be combined on a single detail line item. KMAP uses the Medicare Physician Fee Schedule Relative Value file to determine which procedures are appropriately billed with modifier 55. KMAP uses the Glob Days field on the file as a basis to determine proper usage of modifier 55. The following determinations have been made based on the individual indicators.

• This modifier can only be used on procedures which have a Glob Days field equal to 010 or 090 on the Medicare Physician Fee Schedule Relative Value file. Any procedure billed to Medicaid that has been assigned global surgery days equal to 010 or 090 will process as normal.

Complete definitions of the Glob Days indicators are available on the CMS website. Once  within the document, perform a word search for MPFSDB Record Layouts and look for the particular year in question (such as 2008, 2009).


When limited comparative radiographic studies are performed (e.g., post-reduction, post-intubation, post-catheter placement, etc.), the CPT code for the radiographic series should be reported with modifier 52 indicating that a reduced level of interpretive service was provided. This requirement does not apply to OPPS services reported by hospitals.

Diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59. If it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier 52 in addition to modifier 59 to the angiogram CPT code. If the prior diagnostic angiogram (fluoroscopic or computed tomographic) was complete, the provider should not report a second angiogram for the dye injections necessary to perform the percutaneous intravascular interventional procedure.





 

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