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07.09.12 - Updated 03.20.13

Reduced Services (CPT Modifier 52) and Discontinued Procedures (CPT modifier 53): Coding, Documenting, and Payment

As CGS reviews services submitted with CPT modifiers 52 (reduced service) and 53 (discontinued procedure), we have identified helpful information about how payments are calculated when these modifiers are submitted as well as submitting them appropriately and ensuring that you have proper supporting documentation.

CPT Modifier 52: Reduced Services

  • This modifier is used to report a service or procedure that is partially reduced or eliminated at the physician's election.
  • Submit CPT modifier 52 with the code for the reduced procedure.
  • Do not submit CPT modifier 52 to report an elective cancellation of a procedure before anesthesia induction and/or surgical preparation in the operating suite. You may not submit CPT modifier 52 if the procedure is discontinued after administration of anesthesia.
  • Do not submit CPT modifier 52 with Evaluation & Management (E/M) services.

Guidelines for claim submission and documentation:

  • Submit the reason for the reduced service in the electronic documentation field (or, if you are approved to submit paper claims, in Item 19).
  • Check the CPT code requirements. For example, many ophthalmology codes are unilateral AND/OR bilateral. Submitting CPT modifier 52 with one of these codes will result in an incorrect payment.
  • Make sure you are submitting the correct modifier. If a procedure is a failed operative procedure or a reduced operative procedure after induction of anesthesia and after the start of the operative procedure, there are more appropriate modifiers to indicate cancelled or discontinued procedures.
    • Ambulatory Surgery Centers (ASCs): refer to CPT modifiers 73 and 74.
    • Physician claims for services performed in ASCs: refer to CPT modifier 53.

Payment:

  • Payment for radiology services, including mammograms, will be reduced by 50%.
  • Payment for surgical services will be reduced based on documentation of amount of service performed and reason for reduced service. Please note: CGS may request additional documentation for surgical service claims, such as an operative report.
  • Payment for timed codes will be prorated based on the length of time for actual service, with a base payment of 25% of the fee schedule amount.

CPT Modifier 53: Discontinued Procedures

  • Submit CPT modifier 53 with surgical codes or medical diagnostic codes when the procedure is discontinued because of extenuating circumstances.
  • This modifier is used to report services or procedure when the services or procedure is discontinued after anesthesia is administered to the patient.
  • Do not submit CPT modifier 53 to report an elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite.
  • Do not submit CPT modifier 53 when a laparoscopic or endoscopic procedure is converted to an open procedure.

Guidelines for claim submission and documentation:

  • Submit the length/amount of procedure completed and reason for discontinuing service in the electronic documentation field (or, if you are approved to submit paper claims, in Item 19).

Payment:

  • Payment for discontinued procedures is based on percentage of service completed. Please note: CGS may request additional documentation for these claims.

References:


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