Are you leaving the money on the table for every other procedure that was initiated but could not be completed? If yes, this guide will help you get paid for your time and effort, ensuring a profitable practice.
But how exactly? In this guide, we are going to discuss an integral two-digit code that indicates to the payer that the procedure was started but couldn’t be finished. Now, to be clear, there are two such codes, but this blog will cover everything you need to know about modifier 52 only.
Once you have completed reading it, you will walk away with information such as: (1) where it applies, (2) when you should avoid using it, and (3) documentation requirements. So, continue reading!
Modifier 52 – Description
Modifier 52 indicates that a service or procedure was partially reduced or eliminated under certain circumstances at the physician’s discretion.
Modifier 52 – Usage Examples
Discussed below are a couple of the real-world clinical scenarios that necessitate the use of this modifier:
Incomplete Endoscopic Visualization Due to Anatomy
Assume a 39-year-old male patient with a history of unexplained hoarseness and a persistent feeling of a lump in the throat. Thus, the physician orders flexible fiberoptic laryngoscopy to examine the laryngeal structure and vocal cords.
However, upon insertion of the scope, the patient starts to exhibit an immediate, severe, and persistent gag reflex. The healthcare provider tries to control the condition, but he is unable to advance the scope past the base of the tongue to visualize the larynx or vocal cords. As a result, he stops the procedure.
Therefore, you should report CPT code 31575 with modifier 52.
Unsuccessful IUD Insertion Due to Cervical Stenosis
Imagine a 25-year-old female patient who comes to the OBGYN clinic for a scheduled insertion of a long-acting reversible contraception (LARC) device.
The gynecologist makes several attempts to sound the uterus and dilate the cervix, but in vain. The reason? He encounters severe, unexpected cervical stenosis (narrowing), preventing the intrauterine device (IUD) from being placed.
Thus, modifier 52 applies to CPT code 58300.
Accurate Usage Guidelines for Modifier 52
Learning what a modifier represents is one thing. However, its appropriate usage requires you to gain knowledge about where to use it, and when to avoid it. This section will cover it, and more:
Understand When You Should Append Modifier 52
The key criteria for accurate application include the following:
Elective Reduction
The physician performing the service intentionally reduced or eliminated the procedure.
Absence of Anesthesia
When the reduced procedure either required minimal sedation or no anesthesia administration at all.
Incomplete CPT Code Description
Use modifier 52 when the procedural code accurately describes the intended service, but was reduced in scope.
Technical Failure
Append it if the provider initiated the procedure but was unable to complete it due to technical limitations. e.g., equipment malfunction, etc.
Know When NOT to Use Modifier 52
Avoid reporting procedural codes with 52 when any of the following is true:
- The provider terminated the procedure due to patient safety.
- Anesthesia administration was involved in the procedure.
- When an evaluation and management (E/M) service requires less work than usual.
- For correcting a wrong code selection. For instance, you chose a higher-level code, but the actual work did not justify its descriptor fully, so you appended modifier 52. Never do it, because it is not a correction tool.
- If no work is performed, i.e., the procedure was never started.
Fulfill Documentation Requirements
Comprehensive documentation is integral to justify why the service was eliminated or reduced in scope. Thus, ensure to include the following:
- Detailed clinical notes, including the standard pre- and post-procedure information.
- Mention why the physician stopped the procedure before the full scope was achieved, e.g., anatomic stenosis prevented complete endoscopic visualization.
- Explicitly state that there was no patient emergency.
- Explain the specific portion or mention the percentage of service that the physician completed before terminating the procedure.
Modifier 52 vs 53: Clarifying the Difference
The main distinction between 52 and 53 is that: Modifier 52 indicates a procedure that was reduced or eliminated at the physician’s discretion. Contrarily, modifier 53 highlights that the service was terminated due to unforeseen circumstances beyond the provider’s control, e.g., patient safety.
Additionally, you can only append modifier 53 to procedures that involve anesthesia administration.
Final Thoughts on Modifier 52
Before bidding adieu, here’s a quick rundown on what we discussed in this guide!
Modifier 52 is an essential modifier that ensures that healthcare practitioners are paid fairly, even when the intended procedure was partially reduced or eliminated at the physician’s discretion.
However, your documentation must justify why the service was not completed. You must explain the reason for the service reduction, state the percentage of work done, and include detailed clinical notes.
With these guidelines, you will never miss a dollar that is rightfully yours. But, in case you continue to struggle, try partnering with a reliable company like NeuraBill for seamless medical billing and coding services.
FAQs
How does modifier 52 affect reimbursement?
Some payers, like the Providence Health Plan, reduce the reimbursement amount by 50% when you append the 52 modifier to the procedural code. Others pay by the percentage of work done.
Can you use modifiers 52 and 50 together?
No, you cannot report both modifiers together. Modifier 50 indicates bilateral procedure, while 52 identifies reduced services. For example, if a service was originally bilateral but you render it on one side of the body, apply 52 with either RT or LT, but never with 50.
Does Medicare cover modifier 52?
Yes, Medicare covers this modifier.
