What is a 52 modifier in Medical Billing

Definition of Modifier-52

In the CPT® Appendix A, Modifier-52 is stated to be used “under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the modifier ’52,’ signifying that the service is reduced”.

Conditions to use Modifier-52

Using Modifier-52 can be quite confusing sometimes. Therefore it is important to understand what is meant by the phrase ‘partially reduced services’.

The phrase ‘partially reduced services’ refer to the procedures that do not contain bilateral (procedures that are performed on both sides of the body during the same operative session or on the same day) or unilateral descriptors. Such procedures are charged for both sides being tested.

This means Modifier 52 is used to indicate reduced services:

• When a procedure is performed only on side of the body
• The payment is based on payment for testing of both sides.
• Discontinuation of radiology procedures and other services that do not require anesthesia.

For example, a physician performs the CPT code 92250. Here, it is important to note that the CPT code 92250 is independent of a bilateral or unilateral descriptor. Moreover, the payment is based on the payment for testing of both eyes. In this case, if the physician treats only one eye then the service will be considered as ‘partially reduced’. Thus the physician will report the reduced service in Block 19 of the CMS-1500 form in the format—CPT/Modifier i.e. 92250 52 (along with a brief reason for reduction). Also, the use of Modifier-52 will make the abbreviations RT and LT are inappropriate.

The Modifier-52 is not used in the following scenarios:

• The procedure contains bilateral or unilateral descriptors.
• To report procedures where the CPT or HCPCS code itself identifies the reduced service. For example, if a patient undergoes a two-view chest X-ray but the only one-single image is obtained. In this case, the procedure is reported without Modifier-52 as— 71010 (radiologic examination, chest; single view, frontal)
• To report Evaluation and Management (E/M) services.
• To report Discontinued or terminated procedures. Modifier-53 is used to signify “discontinuation of physician services and is not approved for use for outpatient hospital services”.

Calculating the Payment using Modifier-52

To determine the payment, reduce the normal fee by the percentage of the service reduced or not provided. For example, if 75% of the normal service was provided then reduce the amount billed 25%.

Role of Modifier-52 in Medical Billing

Modifier-52 plays an important role in reimbursement for ‘partially reduced services’. However, despite its clear definition and guidelines, using Modifier-52 may prove to be confusing. Incorrect use of Modifier-52 is likely to result in denials or rejected claims and delays the reimbursement process; thus affecting the hospital’s revenue cycle. Therefore, it is advisable to outsource medical billing services from a medical billing company. The medical billing company will provide the assistance of a trained medical biller who will ensure that the Modifier-52 is used correctly.