Friday, May 6, 2011

52 Modifier in Radiology billing

52 Modifier (Reduced Services)
Procedures for which services performed are significantly less than usual may be billed with the 52 modifier.
Procedure  code defines the 52 modifier as “Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s discretion …”

Procedures (i.e., radiology services, Dopplers, surgeries, etc.) for which services performed are significantly less than usually required may be billed with the 52 modifier.
Some of the radiology codes have no code for less than two views. When only one view is performed and there is no code for the single view, the 52 modifier would be used with the multiple view code that describes the procedure performed.
In contrast, an example of when the 52 modifier should not be used is in the billing of procedure code 71020 (radiological examination, chest, two views, frontal and lateral) if ordered when only one view is performed. In this case, there is a code to identify the procedure that was actually done, which would be procedure code 71010 (radiological examination, chest; single view, frontal) and code 71010 should be reported instead of procedure code 71020 52.

The proper use of the 52 modifier would apply when the procedure performed doesn’t have a specific Procedure  code /HCPCS code that describes what was performed, but a code describes most of the performed procedure. The 52 modifier should not be used to describe the procedure that was intended but not completed.

Documentation supporting a claim for non-surgical services must contain appropriate documentation.
For radiology services submitted with the 52 modifier, the claim must contain a statement as to how the reduced service is different from the standard service. You may include other documentation (submitted with claim or faxed) but it is not necessary if the statement can convey the scope of the reduced service. If a statement explaining the reduction of the service or procedure is not submitted, the code billed with the 52 modifier will be denied.

Example 1: S&I radiological code was given and the radiologist did not supervise the service. The statement should reflect that no supervision was provided.

Example 2: Diagnostic ultrasound when less than a “complete” exam is reported (e.g., limited number of organs or limited portion of region evaluated). The statement should reflect which organs/portions of “complete” exam were not evaluated.

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