Saturday, 21 January 2017

Modifier 50, 51, 52, 53

Modifier 50

Bilateral Procedure


When performing a procedure on bilateral body parts, append payment modifier 50 to the appropriate code performed at the same session. The bilateral adjustment is inappropriate for (a) physiology or anatomy codes or (b) code descriptor that specifically states it is a unilateral procedure and there is an existing bilateral procedure code.

Correct Use

One line appending modifier 50 or RT and LT using one unit of service
See Bilateral Surgery Rules within Medicare Physician Fee Schedule (MPFS) Indicator Descriptions

Incorrect Use
  • Inappropriate to apply an already "bilateral description" code.
  • Do not append to procedures for midline organs such as the bladder, uterus, esophagus or nasal septum.
  • Inappropriate to report when performed on different areas of same side of body.

Claim Coding Example

Treatment Description : Total Knee Arthroplasty

CPT 27447 /Modifier 50

Modifier 51

Multiple Procedures. When multiple procedures, other than Evaluation and Management (E/M), Physical Medicine and Rehabilitation services or provisions of supplies (e.g., vaccines) are performed at the same session by the same individual, the primary procedure or service may be reported as listed. Multiple procedure rules apply to the secondary procedure or service.


Do not append modifier 51 to the additional procedure code. The Medicare claim processing system has a hard coded logic to append it to the correct procedure code. CPT also lists codes that are modifier 51 exempt.

Correct Use

Below are situations when multiple procedure rules apply.
  • Append when same physician performs more than one surgical service at same time (Indicator 2)
  • Append when technical component of multiple diagnostic procedures, Multiple Procedure Payment Reduction (MPPR) rule apply (Indicator 4)
  • Append when multiple surgical procedures are done on same day but billed on two separate claims

Incorrect Use
  • Do not append modifier 51 to additional procedure code
  • Do not append to add-on codes (See Appendix D in the CPT manual)
  • Do not append to all lines of service
  • Do not append when two or more physicians each perform distinctly, different, unrelated surgeries on same day to same patient

Modifier 52

Partially Reduced or Eliminated Services


This modifier is used to indicate partial reduction, cancellation or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. It also identifies a situation where a physician reduces or eliminates a portion of a service or procedure.

Correct Use
  • Indicate statement "reduced services" in Item 19 in CMS-1500 claim form (or electronic equivalent)
  • Include brief reason for reduction
  • Documentation includes complete reduction reason retained in patient's record
  • To determine charge amount, reduce normal fee by percentage of service not provided
  • E.g., if 75% of normal service provided, reduce amount billed by 25% 
  • Medicare claims processing system reimburses lower of actual charge or fee schedule allowance  
Example: Provider performs 75% of service and appends modifier 52

Medicare Physician Fee Schedule (MPFS) allowed amount* : $100

Reduced Billed Amount ($100 x 75%) : $ 75
*Medicare recognizes that many providers use one standard fee schedule for all insurance carriers. Therefore, reducing the charge amount may differ from the example.

Incorrect Use
  • Do not confuse with "terminated procedure" modifier 53
  • Inappropriate with E/M codes
  • Inappropriate with facility billing
  • Not for use in Ambulatory Surgical Center (ASC) or outpatient hospital
Special Appeal Instructions
  • When submitting the Redetermination request
  • Separate, concise statement explaining necessity for allowable reduction
  • Submit operative report and/or chart notes
Claim Coding Example

This bilateral procedure was performed on one eye (unilateral) only. Since the code is allowed at a bilateral rate, the provider must append modifier 52 to reduce charges. In this case, it is not appropriate to use RT or LT.

Treatment Description : Fundus photography with interpretation/report; bilateral
CPT 92250 /Modifier 52

Modifier 53

Discontinued Procedure (professional services only)


This 53 modifier allows the physician community to state the surgical procedure was discontinued due to extenuating circumstances or a threat to patient well-being.  

Correct Use
  • Append in first pricing position.
  • Under certain circumstances, physician may elect to terminate surgical or diagnostic procedure.
  • Surgical or diagnostic procedure started and discontinued by physician.
  • Prior to or after anesthesia is administered.
  • Bill Medicare the percentage of service completed (see second example below).
  • Medicare Claims Processing System does not automatically reduce payment.
Incorrect Use

Inappropriate with E/M or anesthesia codes
Do not use to report elective procedure cancellation, in the operating suite, prior to patient's anesthesia induction and/or surgical preparation
Inappropriate to use for Ambulatory Surgery Center (ASC) or hospital facility claims
Use facility modifiers 73 or 74
Do not confuse with "reduced procedure" modifier 52

Claim Coding Example

Treatment Description : Sigmoidoscopy; flexible; diagnostic

CPT 45330 /Modifier 53

Claim Reduction Fee Example

Provider performs 60% of service, reducing charges and appends modifier 53.

Medicare Physician Fee Schedule (MPFS) Allowed* : $200

Bill Reduced Amount ($200 x 60%) : $120

*Medicare recognizes that many providers use one standard fee schedule for all insurance carriers. Therefore, reducing the charge amount may differ from the example.

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