MA PPO

Modifier 52 Reduced Services
MA03.014a


Policy

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.

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

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)
N/A

Revenue Code Number(s)
N/A

Modifiers

Modifier 52 Reduced Services

Coding and Billing Requirements



Policy History

1/13/2020
1/13/2020
MA03.014
Claim Payment Policy Bulletin
Medicare Advantage
Yes