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Policy No:  115

Originally Created: 01/01/2017

Section:  Modifiers

Last Reviewed: 03/01/2019

Last Revised: 01/01/2017

Approved: 03/07/2019

Effective: 04/01/2019

This policy applies only to physicians and other qualified health care professionals.

Definitions

Current Procedural Terminology (CPT®) Modifier 52

Identifies a service or procedure that was partially reduced, that services performed were significantly less than usually required, or eliminated at the discretion of the provider.

Policy statement

Procedure codes submitted with modifier 52 will be reimbursed at a reduced rate. Our health plan reimburses procedure(s) appended with modifier 52 at 50% of the allowable amount.  Procedure codes for any other procedure not performed at all should not be additionally reported.

When an inherently bilateral procedure is performed unilaterally, resulting in the service being reduced, (such as 22840 – spinal instrumentation), modifier 52 should be reported.

When a procedure code does not exist to report a lower level of service, modifier 52 may be reported (such as 73520-Radiological examination, hips, bilateral, minimum of 2 views of each hip, but only one view of each hip was performed).

Our health plan considers the following, but not limited to, inappropriate usage for modifier 52:

  • Time based codes
  • All-or-nothing procedure codes (e.g. 72020 XR spine, single view; 97010 – 97028 PT modalities, one or more areas, non-timed codes)
  • Unlisted procedure codes
  • Evaluation and management (E&M) codes
    • Select the code that best describes the level of service performed. If services documented do not meet the criteria for the lowest level of E&M available, then the service is not reportable

Procedure code/modifier combinations that are considered not valid for our health plans use will be denied.

References

Centers for Medicare & Medicaid Services (CMS). National Physician Fee Schedule Relative Value File

American Medical Association. "Appendix A: Modifiers" Current Procedural Terminology (CPT). AMA Press

Cross References

Modifier 53; Discontinued Procedure

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.