Monday, August 9, 2010

Reduced Service - Medicare modifier 52

Modifier 52 Fact Sheet


• Reduced Service reports a partially reduced or eliminated service or procedure.

Appropriate Usage:

• Procedures for which services performed are significantly less than usually required may be billed with the “52" modifier.

• Report the service provided with modifier 52 and the appropriate reduced original charge.

• Services modified at the physician's discretion to be less than the usual procedure.

• When the documentation describing the service fully supports that the service furnished was less than usually required.

Inappropriate Usage:

• Do not use for terminated procedures.
• Do not use for situations when the patient has the inability to pay the full charge.
• Do not use on a time-based code (i.e. anesthesia, psychotherapy or critical care).
• Do not report on Evaluation & Management and Consultations codes.

Additional Information:

• Claims need to indicate “Documentation available upon request” in item 19 or the electronic  equivalent.

• Reduce the amount you normally bill for the service(s) on your claim accordingly.

Usage Guidelines CPT Modifier 52 – Reduced Services

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 CPT 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 and/or 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 CPT modifiers 73 and 74

** Use of this modifier requires additional documentation such as an operative report and a concise statement specifying how the service differs from the usual.

** This information must be indicated in the appropriate documentation record for electronic claims or sent via FAX. It may also be attached to the CMS-1500 claim form for paper claims.

** Failure to submit this documentation appropriately may result in services rejected as unprocessable.

The normal full charge billed or a reduced charge for the procedure may be submitted. Blue Cross will pay the lesser of either 90% of the physician fee schedule allowance for the  procedure or the charge submitted.

Do not use modifier 52 with:

• Evaluation and management codes.

• When another code is available to describe a lesser service.

• With an all-or-nothing procedure code.

• With an unlisted code.

When modifier -52 is used to indicate reduced services, the billing office should indicate what was different about the procedure (how was the service reduced) and approximately what percentage of the usual work was completed and/or not done.

• In some simple cases, this can be done with a brief statement of additional information on the claim itself. Most electronic clearinghouse services have fields to accommodate and transmit this additional information.

o If the procedure code is time-based (e.g. “each 15 minutes” or “each additional hour”), indicate on the claim how much time was actually performed.

o If less than the specified number of views were performed for a radiology procedure code, ensure that no other code exists for the number of views done, and indicate on the claim the number of views performed (e.g. 74010-52 “two views”).

o When an inherently bilateral procedure is performed unilaterally, a claim notation can be made to indicate the procedure was only performed on one side (e.g.
93921 “left leg only”, 92556 “right ear only”).

• If the nature and extent of the reduction cannot clearly and completely be explained with a notation on the claim itself, then a letter or statement should be attached to the claim, and the medical records documenting the service should also accompany the claim (e.g. operative report, radiology report, visit notes, etc). Generally this means

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