Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

Modifier 52: Reduced Services

Notification Issue Date:

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

Title:

Modifier 52: Reduced Services

Policy #:

MA03.014b

Policy

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 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.

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

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).

Description

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

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 September 15, 2021.

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 15, 2021.

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

MPMiscCodesNarrativesPub
Modifiers

52	Reduced Services

Coding and Billing Requirements

Cross Reference

Policy History

REVISED FROM MA03.014b

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.

REVISED FROM MA03.014a

01/13/2020