Sunday, May 30, 2010

Modifier 52 - Reduced service from the intended procedure.

Part - A  Level I Modifiers - 52

Description Reduced service from the intended procedure.

Required for Claims Hospital Outpatient Prospective Payment System (OPPS)

Type of Bill: 12X, 13X

Coding Guidelines Generally applied to radiological procedures (CPT 70010-79999)

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
    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

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
    Inappropriate with facility billing
        Not for use in Ambulatory Surgical Center (ASC) or outpatient hospital
        See modifiers 73 or 74

Special Appeal Instructions

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

General Guidelines

A. If a portion of the intended procedure was completed and a code exists which represents the completed portion of the intended procedure, the CPT/HCPCS code representing the completed portion should be use. In this situation, no modifier –52 should be used. (Example: Patient was scheduled for a CT scan of the head with an without contrast. Only the CT scan without contrast was able to be performed. In this case, the CT scan indicating without contrast would be coded and no modifier would be indicated.)

B. If no CPT/HCPCS code exists for the portion of the procedure or service that was done, report the intended procedure/service CPT/HCPCS code with modifier –52. If multiple procedures were scheduled, only report the first planned procedure followed by modifier –52.

C. Modifier -52 is used to indicate partial reduction or discontinuation of radiology procedures and other services that do not require anesthesia. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service.

D. An elective cancellation of a procedure should not be reported.

E. If a procedure is terminated prior to the induction of anesthesia and before the patient is wheeled into the procedure room, the procedure should not be reported. The patient has to be taken to the room where the procedure is to be performed in order to report modifier –52.

F. Modifiers -52 and -53 are no longer accepted as modifiers for certain diagnostic and surgical procedures under the hospital outpatient prospective payment system.



Hospital Outpatient Prospective Payment System (OPPS): Use of Modifiers –52, –73 and –74 for Reduced or Discontinued Services



Background

Because of recent questions received by the Centers for Medicare & Medicaid Services (CMS), CR 3507 was issued to clarify:

• The definition of anesthesia for purposes of billing for services furnished in the hospital outpatient department, and
• The CMS policy regarding the use of modifiers –52, –73, –74 reported under OPPS.

For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include:

• Local, regional block(s),

• Moderate sedation/analgesia (“conscious sedation”),

• Deep sedation/analgesia, and



The OPPS modifiers –52, –73 and –74 are used to report procedures that are discontinued by a physician due to unforeseen circumstances, and for surgeries and certain diagnostic procedures requiring anesthesia:

• The hospital may receive 50 percent of the OPPS payment amount for the discontinued procedure if:

• The procedure is discontinued after 1) the beneficiary was prepared for the procedure and 2) the beneficiary was taken to the room where the procedure was to be performed.

• The hospital may receive the full OPPS payment amount for the discontinued procedure if:

• The procedure is discontinued after 1) the beneficiary has received anesthesia or 2) the procedure was started (e.g., scope inserted, intubation started, incision made). To provide additional clarity:

• Modifier –73 is used by the facility to indicate that a surgical or diagnostic procedure requiring anesthesia was terminated due to extenuating circumstances that threatened the well being of the patient after the patient had been prepared for the procedure and been taken to the procedure room.

• Modifier –74 is used by the facility to indicate that a surgical or diagnostic procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started, e.g., the incision made, intubation started, or scope inserted.

• Modifier –52 is used to indicate partial reduction or discontinuation of radiology procedures and other services that do not require anesthesia. Note that discontinued radiology procedures that do not require anesthesia may not be reported using modifiers –73 and –74.


OVERVIEW

As defined in the Current Procedural Terminology (CPT®) book, under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician, hospital, ambulatory surgical center or other qualified health care professional. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52 (reduced services), signifying that the service is reduced. This provides a means of reporting the reduced services without disturbing the identification of the basic service.

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.

REIMBURSEMENT GUIDELINES

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. Oxford's standard for reimbursement of modifier 52 is 50% of the Allowable Amount for the unmodified procedure.

This modifier is not used to report the elective cancellation of a procedure before anesthesia induction, intravenous (IV) conscious sedation, and/or surgical preparation in the operating suite.


Modifier 52 should not be used with an evaluation and management (E/M) service.



DEFINITIONS

Allowable Amount: The dollar amount eligible for reimbursement to the physician or health care professional on the claim. Contracted rate, reasonable charge, or billed charges are examples of Allowable Amounts.

Modifier 52: Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. 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.

Billing and reimbursement

For Network Health to consider reimbursing a reduced service, providers must append Modifier 52 to the appropriate claim service code. Providers cannot use Modifier 52 for reporting an elective procedure cancellation prior to a member’s anesthesia induction and/or surgical preparation in the operating suite. When providers submit a claim with Modifier 52,

Network Health requires a letter or statement to accompany the claim, indicating the difference in the procedure. An operative report must accompany the claim when providers perform a surgical procedure.

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