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Modifier 52 is described as a way to reflect fewer or discontinued services when used with surgical or diagnostic CPT codes. This means that CPTs represent surgical or diagnostic services that the provider chooses to minimize. It appears to be comparable to Modifier 53 for terminated services at first appearance. Though these two modifiers are employed in comparable situations, it is crucial to remember that there are clear differences in their proper usage.
Applying these two specific modifications to your claims might result in underpayments or denials and create confusion. Modifier 52 is typically used for treatments that do not require anesthesia. The reduction in service must be purposeful, not the result of unanticipated circumstances. Detailed evidence is obligatory to justify the use of modification 52.
What is Modifier 52?
The qualifying reduced service codes for modifier 52 are extremely restrictive. According to CPT® Appendix A, “In certain circumstances, a service or treatment may be partially reduced or omitted at the physician’s discretion. Under these conditions, the service supplied can be identified by its typical process number plus the modifier ’52,’ which indicates that the service is eliminated
The circumstances for applying modifier 52 would not include an unexpected change to the procedure by the provider; therefore, to append modifier 52 effectively, you must understand why the provider lowered the services. Because modifiers 52 and 53 are closely related, understanding the “why” behind what was done can help determine which should be employed. An essential reminder about the guideline for most modifiers: 52 should not be used when a CPT exists that better captures the circumstance you are attempting to report.
Modifier 53 is used when an operation is canceled owing to unexpected circumstances, such as equipment failure or patient intolerance. It is crucial to grasp the distinction between modifiers 52 and 53 based on the reason for the service reduction. To ensure appropriate coding and reimbursement, always refer to relevant payer rules. To help illustrate when a suitable condition may emerge, consider some examples of modifier 52 in use.
A Few Clinical Situations
- A ten-year-old patient undergoes a unilateral tonsillectomy (CPT code 42820). In this scenario, use modifier 52. This CPT implies bilateral surgery; hence, modifier 52 would be useful to demonstrate that it was only conducted on one side or was electively decreased.
- CPT Assistant (2016) offers a helpful example: “If transvenous extraction fails to remove a transvenous electrode(s), report code 33234, Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular, with modifier 52, Reduced Services.” Depending on the circumstances, modifier 52 is reportable if no anesthetic was delivered and the physician chose to terminate the procedure.
- A surgeon performs a laparoscopic surgery to remove bilateral pelvic lymph nodes. The full surgical description includes a “total pelvic lymphadenectomy and peri-aortic lymph node sample (biopsy), single or multiple.” However, the surgeon eliminates everything but the internal iliac nodes. As the doctor chose not to remove the internal iliac nodes, modification 52 indicates a reduction in services for this treatment.
- If a colonoscopy is started but not finished due to the patient’s intolerance or issues, Modifier 53 is used.
- If the patient’s vital signs become unstable during a surgical procedure and the surgery is halted to ensure the patient’s safety, Modifier 53 is used.
When is Modifier 52 not needed?
Here, you need to understand the situation where a specific modifier is not required.
- The code description mentions unilateral and bilateral.
- An existing CPT or HCPCS code accurately identifies the reduced service.
- The procedure was terminated due to issues with anesthesia delivery and/or the patient’s safety.
Sum up
Depending on why the doctor stopped the operation, one can choose between modifier 53 for eliminated services and modifier 52 for limited services. Remember that modification 52 is for reduced services, even though these two modifiers may appear to be comparable at first glance. When adding modifier 52 to a claim, do not forget to save the records indicating the reasons for the procedure’s shortening.
Hence, necessary information should be included on the documents to let the payer decide whether to reimburse the determination. Correct reimbursement requires the accurate and proper use of modifiers. For particular guidance, always consult a coding specialist or refer to payer standards. Read More: Understand the Pain Right Shoulder ICD 10
