CurrentUnitedHealthcarePolicy CMS 1500 Policy Number 2025R0065A

Use and reimbursement of Modifier 52 (reduced services)

Defines UnitedHealthcare Community Plan's reimbursement approach for services billed with CPT Modifier 52 (reduced services) for claims submitted on CMS 1500 and, when specified, UB04 forms; affects providers submitting claims to UHC Community Plan.

Policy Summary

PayerUnitedHealthcare

PolicyUse and reimbursement of Modifier 52 (reduced services)

Policy CodePolicy CMS 1500 Policy Number 2025R0065A

Change TypeState exceptions revised

Effective Date

Next Review Date

Key ActionSubmit accurate claims with appropriate CPT/CMS coding and include required documentation when CMS requires it for Modifier 52 claims.

SourceLink

POLICY UPDATE CHANGES

State exceptions section: Idaho updated.

State exceptions section: Kentucky updated.

50%standard reimbursement of Modifier 52 (allowable amount)

75%CO/ID exception reimbursement

1CMS 1500 policy suffix

Modifier 52 Coverage Criteria

Modifier 52 reimbursement criteria

Reimbursement and usage criteria for CPT Modifier 52 (reduced services).

Standard reimbursement for Modifier 52 is 50% of the Allowable Amount for the unmodified procedure.

Do not use Modifier 52 to report elective cancellation of a procedure before anesthesia induction, intravenous (IV) conscious sedation, and/or surgical preparation in the operating suite.

Modifier 52 should not be used with evaluation and management (E/M) services.

Do not use Modifier 52 when a CPT code exists that represents the completed portion of the intended procedure.

When billed, claims with Modifier 52 may require documentation and may be priced individually after review (submit documentation as required).

Policy Summary

PayerUnitedHealthcare

PolicyUse and reimbursement of Modifier 52 (reduced services)

Policy CodePolicy CMS 1500 Policy Number 2025R0065A

Change TypeState exceptions revised

Effective Date

Next Review Date

Key ActionSubmit accurate claims with appropriate CPT/CMS coding and include required documentation when CMS requires it for Modifier 52 claims.

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.

Coding and Reimbursement Details

Modifier guidanceModifier

Modifier 52

Reduced services — report when service is partially reduced or eliminated by physician discretion; not for use when a code exists for the completed portion.

Reimbursement percentage

Standard reimbursement50% of the Allowable Amount for the unmodified procedure.

Colorado exceptionCodes identified in the Colorado fee schedule follow the fee schedule; all other Colorado codes reimbursed at 75% of the Allowable Amount.

Idaho exceptionReimbursement for Modifier 52 is 75% of the Allowable Amount.

States exempt from this policyIndiana, Kentucky, and Washington, D.C. are exempt from this Modifier 52 reimbursement policy.

Missouri exceptionMissouri will follow fee-schedule reimbursement instead of applying the modifier percentage.

Claim Submission and Provider Requirements

Documentation Required

Claim submission and documentation — submit accurate claims with appropriate CPT/CMS coding; include required documentation when CMS requires it for Modifier 52 claims.

You are responsible for submission of accurate claims. Submit claims that reflect the codes that correctly describe the services provided and include required documentation when CMS requires it for Modifier 52 claims. UnitedHealthcare Community Plan follows CPT, CMS, and other coding guidelines and may apply reasonable discretion when interpreting and applying this policy.

Standard reimbursement: 50% of the Allowable Amount for the unmodified procedure (Modifier 52).
Include supporting documentation when CMS requires documentation for reduced services billed with Modifier 52.

Denial Risk

Prohibited usages — Do not use Modifier 52 for elective cancellation before anesthesia induction/IV sedation/surgical prep or with E/M services.

Do not use Modifier 52 to report elective cancellation of a procedure that occurs before anesthesia induction, IV conscious sedation, or surgical preparation in the operating suite. Modifier 52 must not be used with evaluation and management (E/M) services.

Do NOT report Modifier 52 for elective cancellations prior to anesthesia induction/IV sedation/surgical prep.
Do NOT append Modifier 52 to E/M service codes.

OpenPayer

Use and reimbursement of Modifier 52 (reduced services)

Modifier 52 Coverage Criteria

Coding and Reimbursement Details

Claim Submission and Provider Requirements

Key Definitions