Modifiers Guide - Healthcare

Modifier 52

Channagangaiah

Modifier 52 – Reduced services

Modifier 52 is appended with appropriate procedure code in the following case:

While reporting the appropriate procedure code to the insurance company for reimbursement of the payment, if you find the physician performed the part of the procedure or the service rendered is reduced for the patient under certain circumstances. Then, that appropriate procedure codes should be reported by appending modifier 52 to indicate that the performed service is reduced.

Usage of modifier 52 with examples:

1) Radiology:

Example 1:

Assume the screening is done only on the right breast, but if you check the CPT book we don’t have a separate CPT code for screening a unilateral.

We do have code for screening breast, bilateral (both the sides) that is 77067.

In the above example, since it’s a reduced service, we should report the claim with procedure code 77067 and appended with modifier 52.

Example 2:

Check the CPT code 73070 and 73080 in CPT book:

If the radiological examination of elbow performed in two views, we will report the claim with CPT code 73070.

If it is more than 2 views then we will report the claim with CPT code 73080.

Now assume the radiological examination of elbow performed in one view. If you check the CPT book, we don’t have code for one view. In this case we will report the procedure code 73070 by appending the modifier 52 as it’s a reduced services.

73070 with modifier 52

2) Ophthalmology services:

Contact lens services, by default its bilateral service codes, if the provider performs services for only one eye, then we report the claim by using modifier 52.

For example see the below codes:

  1. 92310
  2. 92314

The above codes are bilateral service. So if the provider performs for only one side, then we doesn’t have separate procedure to report one side. In that case we need to append modifier 52 to report it’s a reduced services.

Same like that if a test is applied to one ear, instead of two ears we need to append modifier 52.

3) Gastroenterology:

If Gastrointestinal tract imaging, intraluminal (eg: capsule, endoscopy), esophagus through ileum, with interpretation and report performed we use the procedure code 91110.

But if the ileum is not visualized, then we append modifier 52 with procedure code 91110.

91110 with modifier 52

4) Cardiovascular System:

Procedure code 36572, 36573, 36584, these procedure codes include the confirmation of catheter tip location.

When performed without confirmation of catheter tip location, we should report these procedure codes with modifier 52.

5) Male Genital System:

Circumsion using clamp or other device with regional dorsal penile/ring block, we report the claim with procedure code 54150.

If circumsion using clamp or other device performed without regional dorsal penile/ring block, we report the claim with same procedure code 54150 along with modifier 52. Because we don’t have separate procedure code to report, so we should report with same procedure code along with modifier 52 to indicate it’s reduced services.

54150 with modifier 52

6) Nuclear Medicine:

a) Sleep Medicine Testing:

We should report with modifier 52,

  1. If less than 6 hours of recording for the below procedure codes:
  2. 95800
  3. 95801
  4. 95806
  5. 95807
  6. 95810
  7. 95811
  • If less than 7 hours of recording for the following procedure codes:
  • 95782
  • 95783
  • If less than 4 nap opportunities are recorded for below procedure code:
  • 95805

b) Special EEG Tests:

Special EEG codes 95950 to 95953 & 95956 are used per 24 hours of recording.

Suppose if the recording is 12 hours or less than that, then we report the above codes with modifier 52.

If the recording is more than 12 hours then do not append modifier 52 with the above codes.

7) Colonoscopy:

If the therapeutic procedure, done beyond splenic flexure but not to the cecum, then we need to report the appropriate codes from (45379-45398) with modifier 52 as per the guidelines.