Description

Per the Current Procedural Terminology (CPT^®) book, under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. Indicate the reduction or elimination of services using Modifier 52 (reduced services).

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reduce payment by 50% when services were reduced, as indicated by modifier 52.

Reimbursement Guidelines

Services submitted with a 52 modifier will receive 50% of the allowed reimbursement.

Multiple procedure reductions will still apply to services submitted with a 52 modifier.

Modifier 52 is not appropriate for the following services:

• Evaluation and management (E/M) services
• Elective cancellation of a service prior to anesthesia induction, (IV) conscious sedation, and/or surgical preparation in the operating suite.
• A portion of the procedure was completed, and an existing code represents the completed portion of the intended procedure.

Rationale

In alignment with CMS and correct coding initiatives, Blue Cross NC will reduce reimbursement for services filed with modifier 52.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross NC web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Related policy

Modifier Guidelines

Discontinued Procedures

References

American Medical Association, Current Procedural Terminology (CPT^®)

cms.gov

History

9/1/2022 New policy developed. Medical Director approved. Notification on 6/30/2022 for effective date 9/1/2022. (eel)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.