Procedure Coding: When to Use the 52 Modifier

Procedure Coding: When to Use the 52 Modifier

This is part of the Modifier Series, the articles include:

Modifier 52 is outlined for use with surgical or diagnostic CPT codes in order to indicate reduced or eliminated services. This means modifier 52 should be applied to CPTs which represent diagnostic or surgical services that were reduced by the provider by choice.

At first glance, it may seem modifier 52 is similar to modifier 53 for discontinued services. However, an important point to note is that while these two modifiers are used under similar circumstances, they’re distinctly different in how they should be correctly used. These two particular modifiers can cause confusion, and applying them incorrectly to your claims can lead to underpayment or denials. We’ve examined modifier 53 in a separate article in this series, so now let’s take a closer look at modifier 52 and when it should be appended.

Defining Modifier 52

As we’ve noted, the qualifying reduced service codes for modifier 52 are very specific. CPT® Appendix A states, “Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier ‘52,’ signifying that the service is reduced.”

Circumstances for applying modifier 52 would not include a change to the procedure that was unexpected by the provider, so in order to append modifier 52 appropriately, you need to know why the services were reduced by the provider. Since modifier 52 and 53 are closely related, the ‘why’ behind what was done will help clarify which should be used. An important reminder here on the rule with most modifiers: 52 should not be used when a CPT exists that better describes the scenario you’re trying to report by using modifier 52.

To help illustrate when an applicable situation could arise, let’s look at examples of modifier 52 in appropriate use.

Clinical Scenarios

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.

Example Two

A surgeon performs a laparoscopic procedure for removal of bilateral pelvic lymph glands. The full description of the procedure includes “total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple.” However, the surgeon removes all except the internal iliac nodes. As the doctor elected to stop short of removing the internal iliac nodes, appending modifier 52 alerts to the reduction in services for this procedure.

Example Three

CPT Assistant (2016) also provides a valuable example: If removal of a transvenous electrode(s) was attempted by transvenous extraction, but was unsuccessful, report code 33234, Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular with modifier 52, Reduced Services … Depending on the circumstances as to why the procedure was stopped, modifier 52 is reportable if no anesthesia was administered and the physician elected to terminate the procedure.”

When Not To Use Modifier 52

  • The code description includes unilateral or bilateral.
  • An existing CPT or HCPCS code properly identifies the reduced service.
  • Anesthesia administration and/or the patient’s wellbeing at risk were factors in ending the procedure.

Summary

Choosing between modifier 53 for discontinued services and modifier 52 for reduced services is all dependent on the physician’s reason for stopping the procedure. While these two modifiers may seem similar on the surface, just keep in mind that modifier 52 is for reduced services. If you’re appending modifier 52 to a claim, remember to maintain documentation explaining why the procedure was cut short. The documentation should provide plenty of detail to allow the payer to make a reimbursement decision.

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