Palmetto GBA, the current J1 contractor, requires the submission of documentation along with the claim. A concise statement that explains the nature of the reduced service along with any other supporting documentation the provider deems relevant. The concise statement may appear on the operative report but, it must be clearly identified. This statement may be entered in the electronic documentation field or submitted via the fax attachment process. For paper claims, this documentation must be submitted as an attachment to the CMS-1500 claim form. Services that are submitted with CPT modifier 52 that do not include a concise statement will be rejected as 'unprocessable' and must be resubmitted as new claims
Noridian requires the provider to determine the 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 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 | $300 |
| Reduced Billed Amount ($300 x 75%) | $225 |
- Reflect statement “reduced services” in Item 19 (narrative or electronic equivalent)
- Documentation reflecting “reduction” reason retained in patient’s medical record
- Do not confuse with “terminated procedure” modifier 53
- Never use with evaluation and management or anesthesia codes
- When submitting the Redetermination request include:
- A separate, concise statement explaining the necessity for allowable reduction
- An operative report or chart notes
- Performed on one eye; unilateral
- Do not use RT or LT
| Treatment Description | CPT/Modifier |
|---|---|
| Fundus photography with interpretation/report; bilateral | 92250 52 |
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