Policy Statement
Procedure codes submitted with modifier 52 will be reimbursed at a reduced rate. Our health plan reimburses procedure(s) appended with modifier 52 at 50% of the allowable amount. Procedure codes for any other procedure not performed at all should not be additionally reported.
When an inherently bilateral procedure is performed unilaterally, resulting in the service being reduced (such as CPT code 22840 – spinal instrumentation), modifier 52 should be reported.
When a procedure code does not exist to report a lower level of service, modifier 52 may be reported (such as CPT code 73521-Radiological examination, hips, bilateral, minimum of 2 views of each hip, but only one view of each hip was performed).
Our health plan considers inappropriate use of modifier 52 to include, but not limited to, the following:
- Time based codes
- All-or-nothing procedure codes (e.g., CPT code 72020 XR spine, single view; CPT codes 97010–97028 PT modalities, one or more areas, non-timed codes)
- Unlisted procedure codes
- Evaluation and management (E&M) codes
- Select the code that best describes the level of service performed. If services documented do not meet the criteria for the lowest level of E&M available, then the service is not reportable.
Procedure code/modifier combinations that are considered not valid for our health plan’s use will be denied.
References
- Centers for Medicare & Medicaid Services (CMS). National Physician Fee Schedule Relative Value File
- American Medical Association. “Appendix A: Modifiers” Current Procedural Terminology (CPT®). AMA Press
Cross References
- Mod 102 - Modifier 53; Discontinued Procedure
