Modifier 52 fact sheet
First Coast identified claims reporting modifier 52 (reduced services) without supporting documentation or an explanation in the narrative of the claim. To avoid claim rejects and future appeals due to these incorrect claim submissions, we’re providing guidance on how to properly submit a claim when applying this modifier.
Effective August 31, 2023, documentation will be required to process claims submitted with modifier 52. Medical review will no longer send an additional documentation request (ADR) for these claims. Claims with modifier 52 should be submitted with required information in the narrative or supporting documentation following the PWK process outlined below. Claims not containing required information or supporting documentation will be rejected.
Your remittance advice will have the following three messages tied to the service:
- Information requested from the billing/rendering provider was not provided or not provided timely or was insufficient/incomplete. At least one remark code must be provided (may be comprised of either the NCPDP reject reason code, or remittance advice remark code that is not an Alert)
- Incomplete/invalid documentation
- Missing documentation
Modifier 52
Under certain circumstances a service or procedure is partially reduced or eliminated at the provider's discretion.
- Unusual (reduced) circumstances
- The service performed was significantly less than usually required
- To indicate partial reduction of services for which anesthesia is not planned
- Append modifier to the reduced procedure’s CPT code
Inappropriate usage
- To report the termination of a procedure
- When used on time-based codes
- When used on evaluation and management services
How to submit supporting documentation
- You can write additional information to support the modifier in the narrative of the claim.
- If data cannot be written in the narrative, you must submit documentation. Please see below for details on providing documentation:
- Medical review will no longer send an ADR for these claims. Claims with modifier 52 should be submitted with required documentation following the PWK process.
- PWK is a process that allows you to submit documentation with an initial claim. Learn more here.
- Medical review will no longer send an ADR for these claims. Claims with modifier 52 should be submitted with required documentation following the PWK process.
- Supporting documentation should:
- State when the procedure was started
- Explain why the procedure was discontinued
- Notate the percentage of the procedure that was performed