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When should CPT Modifier-52 be used ?


Modifier-52 is used to describe circumstances in which services provided were reduced in comparison to the full description of the service. When a physician does not complete a procedure in its entirety the procedure must be billed by appending modifier-52 or in other words if a physician elects to partially reduce or discontinue the procedure for reasons other than the patients well being being threatned, modifier-52 may be used. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumsatnces or those that threaten the well being of the patient prior to or after adminsitration of anesthesia, see modifier 73 and 74 (see modifiers approved for ASC hospital outpatient use).

Also note that if you have a Co-surgery situation, where the surgeon did not open and close the procedure, you must report the code and append modifier-52.

Following are the three different scenarios where it would be appropriate to use modifier-52.

Scenario 1: An ophthalmologist performed fluroscein angioscopy in only one eye of the patient. Since only one eye is assessed, use modifier-52 to report reduced services. It would be inappropriate to use modifier-50 here.

Scenario 2: A cardiologist attempted to perform a Percutaneous Transluminal pulmonary artery balloon angioplasty of the totally occluded blood vessel. The surgeon could not complete the procedure because of an anatomical problem which prevented him from performing the catheterization. Hence CPT 92997 with modifier-52 should be coded.

Scenario 3: During an open procedure, an Ob-Gyn  calls a general surgeon to perfom an Appendectomy. Since the general surgeon did not open or close the procedure, he must report the CPT 44950 with modifier-52.

When submitting a claim with modifier-52, attach a brief explanation stating the nature of the reduced services and the reason why and any/or all medical documentation supporting the claim. This will help the payer in assessing the fee value to the service performed.

Posted by SMBS Team


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