Description
Reduced services.

Guidelines/Instructions
"Surgical procedures" with the CPT modifier 52 appended requires a complete operative report and a concise statement explaining the nature of the reduced service.

"Non-surgical procedures" with the CPT modifier 52 appended requires a concise statement explaining how the service differs from the usual. This statement will only be accepted in the electronic documentation record and Block 19 of the 1500 form only. 

Failure to include the documentation in the appropriate format will result in claims being rejected as "unprocessable" and must be resubmitted as new claims.

  • This modifier may not be submitted with Evaluation and Management (E/M) procedures
  • For procedures terminated prior to completion and are submitted by:
    • an ASC, refer to CPT modifiers 73 and 74
    • a physician and performed in an ASC, refer to CPT modifier 53
  • Surgical Services Only — Documentation required with the claim for surgical services submitted with the 52 CPT modifier:
    • An operative report corresponding to the surgical service performed
    • A concise statement explaining the nature of the reduced service. The concise statement may appear in the operative report but must be clearly identified. It may be circled, underlined, highlighted or written within the operative report or indicated in the electronic documentation record or Block 19 of the 1500 claim form.
    • For electronic claims, the required documentation must be submitted via the fax attachment process. For paper claims, this documentation must be submitted as an attachment to the 1500 claim form.
    • 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

Special Note for 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
  • 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

Special Note for Ambulatory Surgical Centers (ASCs): Effective for dates of service on or after January 1, 2008, report this modifier for discontinued radiology procedures and other procedures that do not require anesthesia. Other multiple procedure price reductions will not apply when this modifier is submitted by ASCs. Refer to CPT modifiers 73 and 74 for other discontinued procedures.

Special Note for Radiology:

  • This modifier may be submitted with radiology services in which the "supervision" and "interpretation" components are performed by different providers. The services should be submitted with the appropriate HCPCS/CPT modifier based on the supervision (TC) or interpretation (26), followed by CPT modifier 52. 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.
  • 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. The documentation will only be accepted in the documentation record for electronic claims or Block 19 for paper claims and shall be a short description of why the service is submitted as a reduced service, such as "unilateral service."

NON-SURGICAL PROCEDURES — Documentation required for non-surgical procedures not mentioned above:

  • Documentation is to be submitted in the electronic documentation record or Block 19 of the 1500 form for paper claims only
  • Documentation should be a short description of why the services are submitted as a reduced service, such as "right eye," "left ear only," etc.
  • Failure to include the short description in the appropriate electronic documentation record or Block 19 for paper claims will result in claims being rejected as "unprocessable" and must be resubmitted as new claims.

Reference:

Contact Palmetto GBA JJ Part B Medicare

Provider Contact Center: 877-567-7271

Email JJ Part B

Contact a specific JJ Part B department


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