Wednesday, June 15, 2011

MODIFIER 52 - description and guidelines and instruction

MODIFIER 52

Description: 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 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)

Guidelines/Instructions:

•    This modifier may not be submitted with Evaluation and Management (E/M) procedures

•    For procedures that are terminated prior to completion and that are submitted by an ASC, refer to CPT modifiers 73 and 74

•    For procedures that are terminated prior to completion and that are submitted by a physician and performed in an ASC, refer to CPT modifier 53

•    Documentation required with the claim:

o    A concise statement that explains the nature of the reduced service along with any other supporting documentation that the provider deems relevant

o    The concise statement may appear on the operative report, but it must be clearly identified. You may circle, underline, highlight or write the concise statement on the operative report. Failure to submit the appropriate information will result in a denial of the claim.

o    This statement may be entered in the electronic documentation field or submitted via the fax attachment process. Railroad Medicare does not have a fax process. For paper claims, this documentation must be submitted as an attachment to the CMS-1500 claim form.

o    Services that are submitted with CPT modifier 52 that do not include a concise statement will be rejected as 'unprocessable' and must be resubmitted as new claims

•    Special Note for Ophthalmology: Reimbursement for CPT code 92136 includes one professional component (CPT modifier 26) and two technical components (HCPCS modifier TC)

o    If this procedure is performed with a unilateral technical component, submit the technical component with CPT code 92136, HCPCS modifier TC and CPT modifier 52. It is not necessary to submit a concise statement about the use of CPT modifier 52 in this instance. Palmetto GBA will assume that the modifier indicates a unilateral technical component.

o    If this procedure is performed with a unilateral technical and professional component, submit the service with CPT code 92136 and CPT modifier 52. It is not necessary to submit a concise statement about the use of CPT modifier 52 in this instance. Palmetto GBA will assume that the modifier indicates a unilateral technical component.

•    Special Note for Ambulatory Surgical Centers (ASCs): Effective for dates of service on or after January 1, 2008, report this modifier for discontinued radiology procedures and other procedures that do not require anesthesia. Other multiple procedure price reductions will not apply when this modifier is submitted by ASCs. Refer to CPT modifiers 73 and 74 for other discontinued procedures.
•    Special Note for Radiology:

o    This modifier may be submitted with radiology services in which the 'supervision' and 'interpretation' components are performed by different providers. The services should be submitted with CPT modifier 26 followed by CPT modifier 52. Note that these instructions do not apply if one provider has already submitted a claim and been reimbursed for both the 'supervision' and 'interpretation' component.

o    Services for which the billed code represents 'bilateral' when performed 'unilaterally' or when the available code describes more than was captured on the film may be submitted with CPT modifier 52. In the electronic documentation record use a short description of why the service is submitted as a reduced service, such as 'unilateral service.'



Reimbursement Guidelines

Examples of combinations which will deny for invalid modifier combination 52 Modifier 52 (reduced services) signifies that only part of the code description was performed, some parts were omitted.

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. 

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