Modifiers 22, 52, and 53 for Medicare Claims

These three modifiers continue to trip up practices who use them when submitting Medicare claims. As is often the case, the key is to getting your claim paid is submitting good supporting documentation. Medicare won’t pay unless you explain why these procedures required more work or less work than usual, or why you stopped a procedure partway through.

Modifier 22 Increased Procedural Services: Add this modifier to a code when the work required to provide a service is substantially greater than typically required. Documentation must support the additional work and extra payment (e.g., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).

  • Do not append modifier 22 to an evaluation and management (E&M) service.
  • Use it only to report procedures that have a 0-, 10-, or 90-day global period.
  • Submit two separate documents with the claim: (1) an operative report AND (2) a concise statement indicating how the service differs from the usual. The billed amount for the procedure with the 22 modifier should reflect the extra payment above the usual Medicare fee schedule allowed amount.

Modifier 22 examples:

  • Trauma that significantly complicates the particular procedure and cannot be reported with any other procedure.
  • Significant scarring that requires extra time and work.
  • Morbid obesity that causes extra work for the physician.
  • Services that are significantly more complex than described by the CPT code.

Modifier 52 — Reduced Services: Use this modifier when the physician — at his or her discretion — reduces or eliminates a portion of a service or procedure, or when the work required to perform the service or procedure is significantly less than usually required. Documentation must support the appropriate reduced charge for the procedure code.

  • Do not append modifier 52 to an E&M service.
  • Use 52 modifier when the procedure performed doesn’t have a specific CPT/HCPCS code that describes it but a code that describes most of the performed procedure.
  • When using modifier 52 with a surgical procedure code, you must submit an operative report with the claim AND a separate concise statement indicating how the service differs from the usual. If the reduced procedure is nonsurgical, submit a statement or report describing service not provided. To determine the amount to charge, reduce the normal fee by the percentage of the service not provided. For example, if you provided 75 percent of the normal service, reduce the amount billed to Medicare by 25 percent.
  • Do not use it:
    • For procedures that were terminated, i.e., intended but not completed
    • For situations when the patient has the inability to pay the full charge, or
    • On a time-based code (i.e. anesthesia, psychotherapy, or critical care).

Modifier 52 examples:

  • The physician performs a procedure on only one side in a normally bilateral procedure, such as performing pure tone audiometry in only one ear. (For codes whose definitions describe “unilateral or bilateral” service or procedure, you don’t need to use modifier 52 because payment is the same in either case.)
  • A surgeon performing a procedure calls in second surgeon for one task. For example, an orthopedic surgeon performing a procedure sees a mass in the thoracic area and calls in a general surgeon who performs a lumpectomy. The general surgeon would code the lumpectomy and append modifier 52.

Modifier 53 — Discontinued Procedure Add this modifier to a surgical or diagnostic procedure code when the physician elects to terminate the procedure due to the patient’s well-being.

  • Do not append modifier 52 to an E&M service.
  • Do not use this modifier to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.
  • Do not use it on a time-based code.
  • When using modifier 53 to report a surgical procedure, you must submit an operative report. Operative notes must document why and at what point the procedure was discontinued. If the procedure is not surgical, a statement or report of how the procedure performed differed from the usual must be submitted with the claim. Reduce the normal fee by the percentage of the service you did not provide.

Modifier 53 examples:

  • Discontinued colonoscopy, for example due to poor preparation or tortuous colon.
  • After the surgical procedure was initiated and prior to completion, the patient’svital signs diminished to a point where the physician aborted the procedure.

For electronic claims that require additional documentation such as an operative report, use the fax/mail documentation option (PDF) to send TrailBlazer the necessary documents. Physicians who use the paper CMS-1500 claim form must include the additional documentation with the claim when it is submitted.

For additional information, see:

Published Oct. 10, 2011


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