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Modifier -52, part two

Compliance Monitor, February 25, 2005

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Q: Should a -52 modifier ever be appended to G0101? Is there a source that answers this question on Medicare's Web sites? (Editor's note: This question generated a fair amount of discussion after initially appearing in the February 9 Compliance Monitor Q&A. Click here to read the previous answer.

A: There isn't a source that provides information on the use of modifier -52. However, CMS has very specific documentation and medical necessity guidelines to bill and be reimbursed for G0101.

The physician or nonphysician provider (NPP) must document seven of 11 female anatomical parts in order to be reimbursed for G0101. The service is covered once every two years, unless the woman is considered high risk.

Tip:I would recommend billing the -52 modifier with G0101 if your physician or NPP has not met the documentation requirements of G0101 by noting seven of the 11 exam criteria. That said, I would not recommend appending modifier -52 on a frequent or consistent basis; rather, I suggest spending time educating physicians and NPPs to the correct, required CMS documentation for G0101.

It is important to note that some managed care plans do not recognize the -52 modifier, so knowing individual payer requirements is important. Developing a good rapport with your provider representative is key to successful coding and billing.

Note: Our managed care payers and other insurances are not as strict with regard to the provision requiring documentation of seven of 11 anatomical parts, but we hold Medicare as the "gold standard" and therefore expect our providers to document consistently regardless of payer.

This question was answered by Sherry A. Hess, MBA, RHIA, CCS-P, senior project coordinator--PFS, Lancaster (PA) General Hospital.

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