Correct Use of Surgical Modifier 52, Reduced Services

CPT-4 states that sometimes a service or procedure is partially reduced or eliminated at the physician’s discretion.  In this case, the procedure is reported with modifier 52.  This provides a means of reporting reduced services without disturbing the identification of the basic service.

This modifier is not used when one approach is unsuccessful but another approach is then performed during the same surgical session; for example, when a vaginal hysterectomy is unsuccessfully attempted, and is then followed by an abdominal hysterectomy.

When a 52 modifier is used, Medicare’s payment is determined by carrier review of the documentation.

Other payers may process claims with the 52 modifier in a variety of ways.  They may apply a standard percentage discount or they may require copies of the documentation to determine the extent of the procedure.  Some payers do not utilize the 52 modifier for reimbursement purposes.  While ACOG’s Committee on Coding and Nomenclature agrees that some reduction may be appropriate, a standard 50% reduction seems excessive. The Committee recommends appealing if a standard 50% reduction is used.

Example of correct use of 52 Modifier: A patient desires permanent sterilization. After consultation with the physician, a patient elects to have a hysteroscopic approach.

Following assessment of the uterine cavity and fallopian tubes, the physician successfully places the micro-insert in the right tube.  The same procedure was initiated on the left.  Multiple attempts were made to place the micro-insert on the left without success.  The physician elects to terminate the procedure without accomplishing the implant on the left.  The service is reported using CPT 58565, Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placemnt of permanent implants, but a 52 modifier is added because it was a unilateral procedure.

Contact:

Donna Tyler
Manager, Coding Education
dtyler@acog.org

Keisha Sutton
Coding Specialist
ksutton@acog.org