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PAP 269

CPT Modifiers 52 & 53


Provider Administrative Policy

Section
Claims Submission
Policy Date
February 2012
Status/Date
Revised/ June 2012
Provider Type(s)
Hospitals   Physician  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

CPT Modifiers 52 & 53

CPT Modifier 52 = Reduced Services
Use Modifier 52 to report a service or procedure a physician elects to partially reduce or eliminate. It indicates that a procedure accomplished some result, but less than expected. To report a reduced procedure, append modifier 52 to the CPT code representing the reduced procedure.

When appending a modifier 52, providers must also reduce their standard charge amount by the equivalent percentage of the procedure not completed.

Do not use Modifier 52 to report terminated or discontinued procedures (see modifier 53 below).

CPT Modifier 53 = Discontinued Procedure
Use Modifier 53 to report services/procedures discontinued due to extenuating circumstances or services/procedures that threaten the well-being of the patient. It indicates someone started a surgical procedure but discontinued the service before completion. A discontinued or terminated surgery refers to a surgical procedure where the provider cannot accomplish the planned procedure.

When appending a modifier 53, providers must also reduce their standard charge amount by the equivalent percentage of the procedure not completed.

General
You cannot append Modifiers 52 and 53 to E/M codes. Medical records are not required when submitting claims with these modifiers, but must be available upon request. Clinical information documented in the patient's records must support the use of both modifiers and include a statement indicating when the provider discontinued or reduced the procedure and the extenuating circumstances preventing the completing of the procedure.

Also, for outpatient hospital billing, do not use modifiers 52 and 53 to report an elective cancellation of a procedure that normally requires anesthesia. Modifiers 73 and 74 may apply under those circumstances.


Policy History

Date Action Reason
June 2012 Revised Transparent language revision

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