Modifiers 52 & 53
|Effective Date:||July 1, 2018|
||September 27, 2019|
This policy provides guidelines for the reimbursement of services with modifiers 52 and 53 for professional providers.
Reduced Services is used to report a service or procedure that is performed at a reduced level from what is specified by the code descriptor. When a physician or qualified health care professional (QHP) does not complete a procedure in its entirety or elects to partially reduce or discontinue the procedure for reasons other than the patient’s health being threatened, the procedure must be billed by appending modifier 52.
When a physician or QHP decides to terminate a procedure due to extenuating circumstances, such as if the well-being of the patient is threatened, making it necessary to indicate that the surgical or diagnostic procedure was started but discontinued. This circumstance must be reported by appending modifier 53 to indicate the procedure was discontinued.
Do not use modifier 52 or 53 with time-based or Evaluation and Management (E&M) codes.
If the procedure is discontinued and provided by an outpatient hospital or Ambulatory Surgery Center (ASC) refer to modifiers 73 or 74.
|52||50% of the fee schedule|
|53||50% of the fee schedule|
Note: Effective October 1, 2019 the 52 modifier will be reimbursed at 50% of the fee schedule. Any claims with a date of service prior to October 1, 2019 will be reimbursed at 80% of the fee schedule.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
|09/27/19||Added Limitations and Exclusions, Disclaimer and History.|
|10/01/19||Reimbursement percentage change for modifier 52 from 80% to 50% for dates of service 10/01/19 and after.|
Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.