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Published
Notification
Modifier 52: Reduced Services
Notification Issue Date:
N/A
MPNotificationDescriptionPub
This policy update becomes effective 01/13/2020. This policy has been updated to communicate the Company’s position on Modifier 52 Reduced Services.
Claim Payment Policy Bulletin
Title:
Modifier 52: Reduced Services
Policy #:
03.00.32b
MPNewsFLASHPub
Policy
MPPolicyPub
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 policy applies to professional and outpatient facility claims.
Modifier 52, used to indicate that services were performed at a lesser level or that a provider has elected to partially reduce or eliminate the procedure, are eligible for reimbursement consideration by the Company.
When a procedure has been eliminated or reduced at the provider's discretion, append Modifier 52 in the following circumstances:
The provider has chosen to eliminate or reduce the service.
The service performed w
as significantly less than usually required.
To indicate partial reduction of services for which anesthesia is not planned.
It is inappropriate to append Modifier 52 the following circumstances:
The service being reported is any of the following:
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
such cases, Modifier 53 is more appropriate to be reported.
When Modifier 52 is appropriately appended to a procedure
code, the service is eligible for reimbursement at 50 percent of the allowed amount of the procedure.
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. Failure to produce the requested information may result in a denial for the service. Claims submitted with Modifier 52 are subject to pre- and post-payment review and potential denials or retractions for inappropriate use.
Guidelines
MPGuidelinesPub
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).
Description
MPDescriptionPub
Modifier 52 is reported when a provider elects to partially reduce or eliminate a procedure after the patient has been prepared and brought to the room where the procedure or service is to be performed. Modifier 52 represents a way of reporting a partially completed service without altering the identification of the basic procedure.
References
MPReferencesPub
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:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r442cp.pdf
.
Accessed
August 6, 2023
.
Novitas Solutions, Inc. Modifier 52 Fact
Sheet. 04/12/19. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144533
. Accessed
August 6, 2023
.
Optum360.
Understanding Modifiers 2019
. West Salt Lake City, UT: Optum360; 2018.
Coding
CPT Procedure Code Number(s)
MPCPTCodesPub
N/A
ICD - 10 Procedure Code Number(s)
MPICD10ProcCodesNarrativesPub
N/A
ICD - 10 Diagnosis Code Number(s)
MPICD10DiagCodesNarrativesPub
N/A
HCPCS Level II Code Number(s)
MPHCPCSCodesNarrativesPub
N/A
Revenue Code Number(s)
MPRevenueCodesNarrativesPub
N/A
MPMiscCodesNarrativesPub
Modifiers
MPCodeNarrativePub
52 Reduced Services
Coding and Billing Requirements
MPCodingAndBillingPub
Cross Reference
Policy History
MPPolicyHistoryPub
Revisions From 03.00.32b:
09/06/2023
This policy has been reissued in accordance with the Company's annual review process.
12/06/2021
This policy update becomes effective
12
/
06
/2021
. The intent of this policy remains unchanged, but the policy has been updated to clarify the company's coverage criteria for Modifier 52.
Revisions From 03.00.32a:
01/13/2020
This policy update becomes effective 01/13/2020. This policy has been updated to communicate the Company’s position on Modifier 52 Reduced Services.
Revisions From 03.00.32:
11/16/2011
New Claim Payment Policy developed.
Version Effective Date:
12/06/2021
Version Issued Date:
12/06/2021
Version Reissued Date:
09/06/2023
03.00.32
Claim Payment Policy Bulletin
Commercial
MPattachmentdataPub
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