Modifiers

Modifier 52 Claim Submission Billing Reminder

National Government Services found that on many occasions, providers are billing for reduced services with modifier 52 appended to the CPT code; however, they are billing the regular charged amount for the procedure. In some of these cases this type of billing could lead to an overpayment. 

When billing for a reduced service, providers should reduce their fees accordingly to reflect the percentage of the procedure performed. A bilateral procedure code could be reduced by 50% if performed unilaterally. However, other services should have their fees reduced based on the procedure actually performed. Maintaining the same charge for a reduced service is not proper billing. Please make sure that when you submit any CPT code with modifier 52 that you are reducing the billed amount by the appropriate percentage of the Medicare allowed amount, not the usual provider’s fee for the services.

Modifier 52 is not appropriate coding for situations when there is a code that would represent the reduced service that was actually performed. 

Example: CPT code 71020 (radiologic examination, chest, two views, frontal and lateral) is ordered. Only one frontal view is performed. CPT code 71010 (radiologic examination, chest: single view, frontal) is reported. The service is not reported as CPT code 71020-52.

Modifier 52 is not valid for submission with E/M services. 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.  

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Revised 8/4/2022