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Reduced Services Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans

Overview

As defined in 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. Under these circumstances the service provided can be identified by its usual procedure number and the addition of Modifier 52 (reduced services), signifying that the service is reduced. This provides a means of reporting the reduced services without disturbing the identification of the basic service. 

It is not appropriate to use Modifier 52 if a portion of the intended procedure was completed and a code exists which represents the completed portion of the intended procedure. 

Policy Codes

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* COMM-Reduced-Services-Policy.pdf
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Questions & Answers

Q: Is the 50% reimbursement level recommended by professional organizations such as Centers for Medicare and Medicaid Services (CMS)? 

A: CMS takes no stand on the reduced reimbursement percentage for the Modifier 52; however, CMS requires documentation to be submitted with the claim. Claims for surgeries billed with Modifier 52 are priced by CMS on an individual basis only after a review of required documentation. 

Q:  Is it appropriate to report Modifier 52 with radiologic studies or diagnostic services, e.g., post-reduction, post-intubation, post-catheter placement, angiogram, etc.? 

A:  Yes, to communicate a reduced level of such a service it is appropriate to report the CPT or HCPCS code with Modifier 52 appended.