Avoid Reductions By Properly Reporting Modifier 52

Avoid Fee Reductions By Reporting Modifier 52 Properly

If it has become a habit to append modifier 52 every time your medical billing has a service that doesn’t exactly meet a CPT code description, you could be unknowingly cutting your compensation on your submitted claims.

AMA CPT guidelines state that modifier 52 should be used when the physician partially reduces or eliminates a service or procedure at his own discretion. The CMS guide lines state as follows: “when a procedure/service performed is significantly less than usually required”.

What you should do is report the code as usual for the procedure and then append modifier 52 to show that the services for the procedure were reduced.

What you need to watch out for is when the payer has different coding guidelines, that’s when using this method of reporting can cost you monetarily. If you have a situation where you will need to use modifier 52 to show the procedure was lessened from the services included in the code; first of all, make sure that your medical documentation backs it up and is signed off on by the physician. A cover letter explaining the use of modifier 52 is also a good idea for some carriers. Second, check with the payer and find out how they want this reported, this will ensure that you get the maximum reimbursements for the services reported as well as easily meeting the payer’s needs to obtain those reimbursements.

View all Articles by: Melissa Clark, CCS-P