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:
It is inappropriate to append Modifier 52 the following circumstances:
- The provider has chosen to service 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.
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.
- 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.
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.