Otolaryngology Coding Alert

Question: Can I use modifier 52 on 99201 if my provider only captures history and MDM for an office visit?

Oregon Subscriber

Answer: In the rare circumstance when your physician (or NPP) provides a service that does not reflect a CPT® code description, you must report the service as an unlisted service with 99499 (Unlisted evaluation and management service). A description of the service provided in the form of the provider’s notes must accompany the claim. The payer has the discretion to value the service when it does not meet the full terms of a CPT® code description (for instance, only a history is performed). The payer also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician practitioner rate. 

Pitfall: You should not use modifier 52 (Reduced services) with an E/M code. Medicare does not recognize modifier 52 for this purpose, according to CMS Manual (30.6.1 — Selection of Level of Evaluation and Management Service [Rev.1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10]).