8 Feb 2016

MODIFIER 52 & 53

Modifier 52 and 53 are CPT modifiers, used with Surgery and Radiology section CPT codes. Don’t use modifier 52 or 53 with time-based CPT’s


Modifier 52 – Reduced service/Procedure


Modifier 53 – Discontinued service/Procedure


Modifier 52 (Reduced procedure)


Append modifier 52 when the procedure was reduced by the physician on his own decision stating that it’s reduced service.


     1.  When there is no CPT code exists to describe the reduced service provided then we can use modifier 52 with the CPT code which describes the complete procedure.


Eg: CPT 73060 – Radiological examination of Humerus, minimum of 2 views


If the physician order and perform single view there is no CPT code for 1 view 

Humerus, Hence use CPT with modifier 52 (73060 – 52) as Reduced service.


     2.  When the physician performed a procedure on one side only but its bilateral CPT Code, then we should append modifier 52.


Eg: CPT 77057 – Screening mammogram, bilateral (2 view film study of each breast)


If the physician order and perform right or left side breast screening mammogram, code it as 77057 – 52


Note: please make sure there is no other CPT available to describe unilateral procedure then it’s appropriate to use that code instead of using modifier 52.


     3.  Any aborted procedure / attempted procedure but not completed, still we can use modifier 52.


Eg: PICC – If a physician attempted for PICC but not able to complete the procedure. 

Still we can use modifier 52 with appropriate CPT.


     4.  Whenever we are using only the S&I CPT we have to use modifier 52.


Modifier 52 has direct impact on reimbursement, it will reduce the payment.


Modifier 53 (Discontinued procedure)


Append modifier 53 to the CPT code stating that the procedure was started but discontinued.


Due to life threaten situation or other justifying situation of the patient make the physician to terminate a surgical procedure.


When the procedure was reduced by the physician on his own decision then append modifier 52.


Modifier 53 is not to be used when the procedure was cancelled prior to the surgical preparation.


It’s inappropriate to use modifier 53 when a laparoscopic procedure is converted to an open procedure.


When multiple procedures were planned and none of the planned procedures was completed due to life threaten situation of the patient, Then the first procedure is reported with modifier 53 and don’t code the other planned procedures.


If one or more procedures were completed then the completed procedures are reported with appropriate CPT code and the other procedures that are discontinued are not qualified for separate reimbursement.


Best Eg: Colonoscopy, An incomplete colonoscopy would be reported with modifier 53.


Note: ASC (ambulatory surgical center) or outpatient hospital reporting of a previously scheduled procedure that is partially reduced or cancelled as a result of justifying circumstances or life threaten situation of the patient prior to or after administration of anesthesia, Then use modifiers 73 or 74.  



Modifier 73(Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia)



Modifier 74 (Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia)