Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Modifier 52 Reduced Services
Policy #:MA03.014a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

In situations where Modifier 52 is appropriate, the service provided should be identified by its usual Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) code with the addition of Modifier 52, signifying that services were performed at a lesser level, or that the provider has elected to partially reduce or eliminate the procedure.

When Modifier 52 is appended to a procedure, the service is eligible for reimbursement at 50 percent of the allowed amount of the procedure.

APPROPRIATE USAGE

The following circumstances are appropriate for appending modifier 52 when reported by a professional provider and there is not a more appropriate procedure code that represents the extent of the service completed:
  • The provider has chosen to eliminate or reduce the service.
  • The service performed was significantly less than usually required.
  • To indicate partial reduction of services for which anesthesia is not planned.

INAPPROPRIATE USAGE

The following are inappropriate circumstances for appending Modifier 52:
  • The procedure being reported is any of the following types of services:
    • Psychotherapy services
    • Evaluation and management (E & M) services
    • Anesthesia services
  • The provider terminates a procedure due to extenuating circumstances that threaten the safety of the patient. In this instance, Modifier 53 is more appropriate to be reported.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agencies, and therapies, as well as test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Claims submitted with Modifier 52 are subject to post-payment clinical review and potential retractions for inappropriate use.

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.
Policy Guidelines

This policy is consistent with Medicare's reporting requirements. The Company's payment methodology may differ from Medicare.

This policy is consistent with the reporting requirements established by the American Medical Association through their publications on Current Procedural Terminology (CPT) as well as the Centers for Medicare and Medicaid Services (CMS).

Inappropriate billing may result in claim overpayments and subsequent retractions or claim underpayments.

Description

Modifier 52 should be reported when a provider elects to partially reduce or eliminate a procedure. Modifier 52 represents a way of reporting a partially completed service without altering the identification of the basic procedure
References

Centers for Medicare & Medicaid Services. Hospital Outpatient Prospective Payment System (OPPS): Use of Modifiers –52, –73 and –74 for Reduced or Discontinued Services. [CMS Web site]. 02/22/2005. Available at:
http://www.cms.gov/mlnmattersarticles/downloads/MM3507.pdf. Accessed September 17, 2019.

Novitas Solutions, Inc. Modifier 52 Fact Sheet. 04/12/19. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144533. Accessed September 17, 2019.

Optum360. Understanding Modifiers 2019. West Salt Lake City, UT: Optum360; 2018.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifiers:

Modifier 52 Reduced Services


Coding and Billing Requirements






Policy History

REVISED FROM MA03.014a
01/13/2020This policy update becomes effective 01/13/2020. This policy has been updated to communicate the Company’s position on Modifier 52 Reduced Services.

REVISED FROM MA03.014
10/09/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on reporting and eligible reimbursement for Modifier 52 Reduced Services. The references were updated accordingly. The policy was updated to be consistent with current template wording and format.
01/01/2015This is a new policy.




Version Effective Date: 01/13/2020
Version Issued Date: 01/13/2020
Version Reissued Date: N/A