Reimbursements

Category:

Modifiers 52 and 53

Reimbursement Policy: NDRP-GC-004
Section: General Coding
Effective Date: July 1, 2018
Last Reviewed:
February 25, 2019

Description:

This outlines the appropriate use Modifiers 52 and 53 when a service is partially reduced or if it is discontinued.

Definitions:

 Modifier-52: Reduced Services
Modifier 52 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 does not complete a procedure in its entirety, or elects to partially reduce or discontinue the procedure for reasons other than the patient’s well-being being threatened, the procedure must be billed by appending modifier 52. Please refer to CPT coding guidelines for more specific information on the reporting of modifier 52.

 Modifier-53: Discontinued Procedure
In certain situations, a physician may decide 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 the code reported by the physician for the discontinued procedure. Please refer to CPT coding guidelines for more specific information on the reporting of modifier 53.

Policy:

The Plan will reimburse approved service lines reporting modifier 52 at 80% of the allowance.

The Plan will reimburse approved service lines reporting modifier 53 at 50% of the allowance

Additional Information

It is not appropriate to append modifier 52 to Evaluation and Management (E & M) services that require key components to be met.  The coding guidelines for certain E & M services specifically state how many key components are required for each level of E & M. If the requirements are not met, the code cannot be billed.

It is not appropriate to append modifier 52 to a time-based code.