CPT Modifier 52

Description — Reduced services
This modifier is used to report a service or procedure that is partially reduced or eliminated at the physician's discretion.

  • Submit CPT modifier 52 with the code for the reduced procedure
  • Report this modifier for discontinued radiology procedures and other procedures that do not require anesthesia
    • Ambulatory Surgical Center (ASC), refer to CPT modifiers 73 and 74 for other discontinued procedures
    • Physician or practitioners should refer to CPT modifier 53 when the services or procedure is discontinued after anesthesia is administered to the patient
  • Do not submit CPT modifier 52 with Evaluation & Management (E/M) services

Guidelines/Instructions

Surgical Procedures
Requires documentation to be submitted with the CPT 52 modifier:

  • Operative report for the surgical service
  • Concise statement explaining the nature of the reduced service
    • Statement must be indicated in the electronic documentation record or Block 19 of the 1500 claim form; or
    • May appear in the operative report and must be clearly identified by circling, underlined, highlighted or written within the operative report, or indicated in the electronic documentation record or Block 19 of the 1500 claim form
  • Electronic claims — required additional documentation must be submitted through the Palmetto GBA eServices portal or with the Claims Processing PWK Fax Cover Sheet process
  • Paper claims — documentation must be submitted as an attachment with the 1500 claim form

Note: Surgical services submitted with CPT modifier 52 but do not include both the complete operative report and separately identified concise statement will be rejected as "unprocessable" and must be resubmitted as new claims.

Non-surgical Procedures
"Non-surgical procedures" with the CPT modifier 52 appended require:

  • A concise statement explaining how the service differs from the usual service and is  being submitted as a reduced service  
  • Documentation is to be submitted in the electronic documentation record or Block 19 of the 1500 form for paper claims only
  • Note: failure to include the documentation in the appropriate format will result in claims being rejected as "unprocessable" and must be resubmitted as new claims
  • Additional documentation faxed or submitted as an attachment without the concise statement will not be matched with your submitted claim and will result in claim rejection

Radiology Services

  • Require a concise statement explaining how the service differs from the usual service and is being submitted as a reduced service 
  • Submit the statement in the electronic documentation record or Block 19 of the 1500 form for paper claims only
  • Services for which the billed code represents "bilateral" when performed "unilaterally" or when the available code describes more than was captured on the film may be submitted with CPT modifier 52
  • This modifier may be submitted with radiology services in which the "supervision" and "interpretation" components are performed by different providers and there is no CPT/HCPCS code that describes the portion of the service provided. The services should be submitted with the appropriate HCPCS/CPT modifier based on the supervision (TC) or interpretation (26), followed by CPT modifier 52.
  • In situations in which a cardiologist bills for the supervision (the “S”) of the S&I code, and a radiologist bills for the interpretation (the “I”) of the code, both physicians should use a “-52” modifier indicating a reduced service; e.g., only one of supervision and/or interpretation. CMS Guidelines (PDF, 482 KB). 
    • Note that these instructions do not apply if one provider has already submitted a claim and been reimbursed for both the "supervision" and "interpretation" component

Ophthalmology
CPT code 92136

  • Reimbursement for CPT code 92136 includes one professional component (CPT modifier 26) and two technical components (HCPCS modifier TC). It is not necessary to submit a concise statement and/or operative report about the use of CPT modifier 52 in this instance. Palmetto GBA will assume the modifier indicates a unilateral technical component. 
  • If the procedure is performed with a unilateral technical component, add CPT modifier 52 in addition to HCPCS modifier TC
  • HCPCS Modifier TC should be submitted in the first modifier field
  • When CPT code 92250 is performed unilaterally it is not necessary to submit documentation supporting the use of CPT modifier 52 for fundus photography. Palmetto GBA will assume the photography was performed on only one eye. 
  • Submit on a single detail line with CPT modifier 52 (reduced service) in situations where fundus photography was performed on one eye
  • HCPCS modifiers RT and LT are invalid for CPT code 92250
  • Documentation reflecting the reason the service was reduced should be retained in the patient’s medical record

Reference

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