CurrentPremera BluecrossPolicy N/A

Modifier 52 Reduced Services reimbursement

Defines when Premera recognizes Modifier 52 on professional claims and how procedures appended with Modifier 52 are reimbursed; applies to multiple Premera and LifeWise lines of business and products and affects professional (CMS-1500/837P) claims and providers submitting them.

Policy Summary

PayerPremera Bluecross

PolicyModifier 52 Reduced Services reimbursement

Policy CodePolicy N/A

Change TypeReimbursement percentage revised

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionAppend Modifier 52 to indicate a partially reduced service and document what was and was not performed.

SourceLink

POLICY UPDATE CHANGES

Effective with dates of service on and after November 1, 2025, reimbursement for procedures appended with modifier 52 will change from 75% to 50% of the provider's applicable Fee Schedule allowed amount.

50%Reimbursement rate for Modifier 52 effective Nov 1, 2025 (general)

75%Alaska providers reimbursement rate until Feb 5, 2026

Feb 6, 2026Alaska reimbursement changes to

Multiple lines of businessApplies to

ExcludedNot valid with time-based codes

Modifier 52 Coverage and Payment Criteria

Modifier 52 coverage and payment criteria

Stance and operational criteria for reimbursement when Modifier 52 is applied:

Modifier 52 is recognized to indicate the scope of a service or procedure was partially reduced, that services performed were significantly less than usually required, or the procedure was eliminated at the physician's discretion.

Documentation in the member's medical record must identify and explain the circumstances surrounding the reduced service by stating what services were performed and which services were not performed for the procedure code modified.

Modifier 52 is not valid when submitted with any time-based codes (including but not limited to anesthesia, psychotherapy, critical care, or physical medicine time-based codes).

ALL of the following

ONE of

Policy Summary

PayerPremera Bluecross

PolicyModifier 52 Reduced Services reimbursement

Policy CodePolicy N/A

Change TypeReimbursement percentage revised

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionAppend Modifier 52 to indicate a partially reduced service and document what was and was not performed.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing and Documentation Requirements

Documentation Required

Billing and documentation requirements for Modifier 52

Append Modifier 52 to indicate a partially reduced service and ensure the member’s medical record documents the circumstances by identifying what services were performed and which were not for the modified procedure code. Do not bill Modifier 52 with time‑based codes (including anesthesia, psychotherapy, critical care, and physical medicine time‑based codes), with modifier 22 on the same procedure, with E&M office visit or preventive medicine exam codes, with unlisted procedure codes, or with codes described as “Unilateral or Bilateral.” Modifier 52 is also not recognized to represent labor management on maternity delivery codes when delivery is performed by another provider.

Append Modifier 52 on the claim to indicate a reduced or partially performed service.
Document in the member’s medical record what portions of the procedure were performed and which were not.
Do not append Modifier 52 with time‑based codes, modifier 22 on the same procedure, E&M office visit or preventive medicine exam codes, unlisted procedure codes, or codes described as Unilateral or Bilateral.
Do not use Modifier 52 to represent labor management on maternity delivery codes when another provider performs the delivery.

Modifier 52: Definition and Invalid Uses

Modifier 52 — definition

DefinitionModifier 52 indicates the scope of a service or procedure was partially reduced, that services performed were significantly less than usually required, or the procedure was eliminated at the physician's discretion.

Documentation requirementMember medical record must indicate and explain the circumstances surrounding the reduced service by identifying what services were performed and which were not for the procedure code modified.

Scope of applicabilityRecognized when appended to a service submitted on a professional claim (applies to Premera Blue Cross, Premera AK, LifeWise WA, LifeWise Assurance, and Premera HMO lines of business).

Invalid uses and restrictions for Modifier 52

Time-based codesNot valid when submitted with any time-based codes, including but not limited to anesthesia, psychotherapy, critical care, or physical medicine time-based codes.

E&M and preventive codesNot valid with E&M office visit codes or Preventive Medicine Exam codes.

Unlisted and laterality codesNot valid with unlisted procedure codes or codes whose descriptions include 'Unilateral or Bilateral'.

Modifier 22 and maternity labor managementMust not be billed in conjunction with modifier 22 on the same procedure; not recognized to represent labor management on maternity delivery codes when delivery is performed by another provider.

OpenPayer

Modifier 52 Reduced Services reimbursement

Modifier 52 Coverage and Payment Criteria

Coding and Reimbursement Details

Billing and Documentation Requirements

Modifier 52: Definition and Invalid Uses