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Reimbursement Policy: Modifier 52 and Modifier 53

December 1, 2017

Purpose:

The purpose of this policy is to provide guidelines for the reimbursement of eligible services appropriately appended with Modifier 52 and Modifier 53 for professional providers.

Definition:

Modifier 52 is used to report a service or procedure that is partially reduced or eliminated at the physician's election when the procedure was terminated after the patient was prepped and was in the room where the service was to be performed.


Modifier 53 is used with surgical codes or medical diagnostic codes when the procedure is discontinued because of extenuating circumstances after anesthesia is administered to the patient.

Scope:

All products are included, except products where Blue Cross and Blue Shield of New Mexico (BCBSNM) is secondary to Medicare (i.e. Medigap). All other insured, ASO, and government programs products are included.

Policy:

BCBSNM will reimburse appropriately billed CPT codes appended with modifiers 52 and 53 at 50% of the applicable BCBSNM fee schedule amount. Please note Modifiers 52 and 53 do not convert a service that is otherwise ineligible for reimbursement to one that is eligible for reimbursement.

Limitations and Exclusions:

Reimbursement determinations remain subject to all applicable limitations and exclusions, including but not limited to:

  • Member eligibility
  • Plan benefit
  • Medical necessity
  • Provider participation agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic.