Coding for Reduced Services? Make Sure Your Documentation Is In Order

Posted on 8 Jan, 2016 |comments_icon 2|By Chris Boucher

Reduced services claims often require more than just encounter notes.

It’s a denial that’s all too common; you submit a claim for reduced services with modifier 52 (Reduced services) appended, and all is well. Correct?

Well …: The claim might pass muster with the payer; to solidify your claims against denials, however, you should always include the proper documentation. Check out these tips from CGS Medicare toward maximizing revenue when your physician has to reduce her services.

Clarify Why Provider Couldn’t Finish Service

While the dreaded insufficient documentation denial is one of the most common when coding with modifier 52 (Reduced services), the exact type of notes you need to include depends on the answer to a single, simple question: Why didn’t the provider didn’t finish the service?

You can answer this question by meeting provider expectations for modifier 52 services. Providers will expect you to use modifier 52 properly in the correct situations; get ahead of the curve by knowing how to use modifier 52, and get the scoop on the documentation you need when filing these claims.

See also: Make E/M Decision First to Plug Nosebleed Coding Holes

Background: According to CGS, you should use modifier 52 when:

  • Using a code that is indicated as a bilateral procedure, but performed unilaterally (and no unilateral code exists); or
  • Coding for “surgical procedures that are incomplete based on the physician’s medical judgment and decision-making.”

Documentation: When submitting a modifier 52 code, CGS recommends that you:

  • “Submit the reason for the reduced service in the electronic documentation field (or, if you are approved to submit paper claims, in Item 19)”;
  • Double-check your modifier choice, as modifier 52 might not be the best choice. “If a procedure is a failed operative procedure or a reduced operative procedure after induction of anesthesia and after the start of the operative procedure, there are more appropriate modifiers to indicate canceled or discontinued procedures,” CGS states;
  • Include a concise statement about how the service differs from the usual; and
  • Make a copy of the operative report and include it with the claim.


Chris Boucher

Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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