Use These Coding Tips for Modifier -52

Per CPT1, modifier -52 is used when a service or procedure is partially reduced or eliminated at the provider's discretion. Such a situation is identified by using the service's usual HCPCS/CPT code and adding modifier -52, signifying that the service is reduced.

For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers -73 and -74.

Application of modifier -52

Effective 2/22/05: Use modifier -52 to indicate partial reduction or discontinuation of radiology procedures and other services that do not require anesthesia. This includes any procedure that is reduced in work from the HCPCS/CPT code description in the book, except for E/M services. However, for surgical procedures, close attention is needed, as modifier -52 can be confused with modifier -53, which indicates that services are discontinued:

• Reduced service: a service that is purposefully less than the CPT code's description dictates
• Discontinued service: a service that is not completed due to unforeseen circumstances

For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia, and general anesthesia.

Coding tips or abbreviated description for anatomically compatible CPT codes

If modifier -52 is reported, payment may be reduced. Therefore, use the code that explains the extent of the procedure. If no code exists for what was performed, report the intended code with modifier -52.

Examples:

• If a barium swallow is not complete because the patient can't tolerate the barium, assign CPT code 74270-52.
• If only one view of a chest x-ray is performed, do not report 71020-52 (for x-ray, two views? reduced service); instead, report 71010 (x-ray chest, single view).
• Incomplete endoscopies: The CPT introduction of the endoscopy subsection was updated to provide guidance as to when modifier -52 versus -53 should be used. There is also a table within the manual to provide guidance.

Essentially, CPT instructs that when performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier -53 and provide appropriate documentation. On the other hand, if the colonoscopy is therapeutic and the scope does not reach the cecum, report the colonoscopy code with modifier -52.

Note that there is a difference in using modifiers -52 and -53 for upper versus lower endoscopic procedures. For upper endoscopies in which the duodenum is deliberately not examined, append modifier -52, if a repeat examination is not planned, or modifier -53, if a repeat examination is planned.

Examples:

• EGD is performed with scope going into the stomach. The duodenum is not examined, and there is no plan to perform repeat EGD to examine the duodenum. Report the procedure code with modifier -52.
• EGD is performed to check on a gastrointestinal bleed, but the duodenum could not be examined as the stomach is full of blood. The current procedure performs a control of the bleeding, but the provider does want to complete the full examination at a later date. Report the procedure code with modifier -53

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