Jurisdiction M Part B - CPT Modifier 52 (2024)

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Jurisdiction M Part B - CPT Modifier 52 (2024)

FAQs

Jurisdiction M Part B - CPT Modifier 52? ›

Modifier -52 is used to indicate partial reduction or discontinuation of radiology procedures and other services that do not require anesthesia. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service.

Does Medicare accept modifier 52? ›

Medicare does not recognize modifier 52 for this purpose. If modifier 52 is used on an E/M service code, the code will be rejected.

When should modifier 52 not be used? ›

Modifier -52 should not be used if there is another specific procedure code that appropriately describes the lesser or reduced service that was actually performed; the other procedure code is the most appropriate code and should be reported.

What is the difference between modifier 52 and 22? ›

True Blue. -52 signifies reduced services and -22 signifies increased services.

What is the difference between modifier 52 and 53? ›

By definition, modifier 53 is used to indicate a discontinued procedure and modifier 52 indicates reduced services. In both the cases, a modifier should be appended to the CPT code that represents the basic service performed during a procedure.

What are examples to use modifier 52? ›

Example One

A provider performs a unilateral tonsillectomy for a ten-year-old patient (CPT code 42820). In this case, apply modifier 52. This CPT assumes bilateral surgery, so to show that it was only performed on one side, or electively reduced, modifier 52 would be appropriate.

Does modifier 52 affect payment? ›

Append modifier to the reduced procedure's CPT code. Ambulatory surgical centers (ASC) use modifier 52 to indicate the discontinuance of a procedure not requiring anesthesia. Contractors apply a 50 percent payment reduction for discontinued radiology and other procedures not requiring anesthesia.

What is the modifier 52 rule? ›

Modifier -52 is used to indicate partial reduction or discontinuation of radiology procedures and other services that do not require anesthesia. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service.

How much does modifier 52 reduce payment? ›

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.

Does modifier 52 affect the global period? ›

A concise statement about how the service differs from the usual; and • An operative report with the claim. Modifier “-22” should only be reported with procedure codes that have a global period of 0, 10, or 90 days. There is no such restriction on the use of modifier “-52.”

What is the modifier 52 for colonoscopy? ›

Therapeutic colonoscopies that are incomplete (the scope does not reach the cecum during a therapeutic procedure) are reported with modifier 52. It is important to note that the codes for reporting these procedures differ between Medicare and other payors.

Does Medicare accept modifier 53? ›

Incomplete colonoscopies are reported with the 53 modifier. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes. "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement.

Does Medicare want modifier 50? ›

Modifier 50 – Correct Usage

Appropriate usage includes: Use modifier 50 when performing a bilateral procedure during one session and the Medicare Physician Fee Schedule Relative Value File (MPFSRVF), also known at the Medicare Physician Fee Schedule Database (MPFSDB) BILAT SURG indicator is 1 or 3.

When should modifier 53 be used? ›

Definitions. Current Procedural Terminology (CPT®) modifier 53 is used due to certain situations when a physician or other qualified health care professional elects to terminate a surgical or medical diagnostic procedure for extenuating circ*mstances when the well-being of the patient is at risk.

What is an example of a 22 modifier? ›

Additional scenarios where modifier 22 could apply include maternity care involving cesarean delivery of multiple gestations, encountering exceptionally large tumors during a procedure or an event of excessive blood loss during surgery.

What is modifier 22 used for? ›

Modifier -22: Increased Procedural Services. This modifier is used to identify a service that requires significantly greater effort, such as increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required, than is usually needed for that procedure.

Does Medicare accept modifiers? ›

Modifiers can be alphabetic, numeric or a combination of both, but will always be two digits for Medicare purposes.

Does Medicare recognize modifier 53? ›

Incomplete colonoscopies are reported with the 53 modifier. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes. "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement.

Can you bill a 50 modifier to Medicare? ›

If a procedure is authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator 1), the procedure shall be reported on a single line item with the 50 modifier and one service unit. Whenever the 50 modifier is appended, the appropriate number of service units is one.

Does Medicare accept modifier 51? ›

Medicare will forward the claim information showing Modifier 51 to the secondary insurance. Multiple surgery pricing also applies to assistant at surgery services. Multiple surgery pricing applies to bilateral services (modifier 50) performed on the same day with other procedures.

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