Notification

Modifier 52 Reduced Services


Notification Issue Date: 08/18/2011

The policy will become effective on 11/16/2011. The following new policy has been developed to communicate the Company's reporting criteria for Modifier 52 Reduced Services.



Claim Payment Policy


Title:Modifier 52 Reduced Services

Policy #:03.00.32

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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) and the addition of Modifier 52, signifying that services were performed at a lesser level, or the provider has elected to partially reduce or eliminate the procedure.

When Modifier 52 is appended to a procedure, the service(s) are eligible for reimbursement at 50 percent of the provider's applicable contracted rate.

It is appropriate to append Modifier 52 for circumstances where the provider has chosen to eliminate or reduce the service and there is not a more appropriate HCPCS or CPT code that represents the extent of the service completed.

The following are inappropriate circumstances for appending Modifier 52:
  • The patient does not have the ability to pay for the service.
  • The procedure being reported is for Time Based HCPCS or CPT codes that include:
    • 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, therapies, and 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.
Guidelines

MEDICARE

This policy is consistent with Medicare's reporting requirements. The Company's payment methodology may differ from Medicare.
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 (CMS). Medicare Claims Processing Manual.Chapter 12 - Physicians/Nonphysician Practitioners. 30.6.6: [CMS Web site]. 06/01/06. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed June 2, 2011.

Highmark Medicare Services. Medicare A/B Reference Manual. Chapter 20: Coding Resources/Modifiers. [Highmark Medicare Website]. 10/19/2010. Available at: https://www.highmarkmedicareservices.com/refman/chapter-20.html#5. Accessed June 6, 2011.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. [CMS Web site]. 06/03/06. Available at:http://www.cms.gov/mlnmattersarticles/downloads/MM3507.pdf. Accessed July 19, 2011.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual.Chapter 8 - Physicians/Nonphysician Practitioners. 30.6.6: [CMS Web site]. Available at http://www.cms.gov/OutpatientCodeEdit/Downloads/Attachment_A_IOCE_Specifications_Document_V113.pdf. Accessed July 19, 2011.


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

Coding and Billing Requirements



Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 11/16/2011
Version Issued Date: 11/16/2011
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.