Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Modifier 53 Discontinued Procedure
Policy #:MA03.018a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

Modifier 53 must be reported when a professional provider terminates a procedure (e.g., surgical or diagnostic) due to extenuating circumstances that may threaten the individual's health or well-being.

When Modifier 53 is appended to a procedure, the service is eligible for reimbursement at 50 percent of the allowed amount of the procedure.

APPROPRIATE USAGE

The following circumstances are appropriate for appending modifier 53 when reported by a professional provider:
  • Health or well-being of individual may be threatened
  • A discontinued procedure after induction of anesthesia

INAPPROPRIATE USAGE

The following circumstances are inappropriate for appending modifier 53 when reported by a professional provider:
  • Any of the following types of services:
    • psychotherapy services
    • E & M services
    • anesthesia services
  • Elective cancellation of a procedure before administering anesthesia and/or prior to surgical preparation in the operating room
  • Termination of a surgical or diagnostic procedure in an outpatient hospital or ambulatory surgical center (ASC). In this instance, Modifier 73 (Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure prior to the Administration of Anesthesia) or Modifier 74 (Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia) is more appropriate to be reported.
  • Partial reduction or elimination of a procedure. In this instance, Modifier 52 (reduced services) is more appropriate to be reported.
  • A laparoscopic or endoscopic procedure that is converted to an open procedure. Only the open procedure should be reported.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agencies, and therapies, as well as test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.
Policy Guidelines

This policy is consistent with the reporting requirements established by the American Medical Association through their publications on Current Procedural Terminology (CPT) as well as the Centers for Medicare and Medicaid Services (CMS).

Inappropriate billing may result in claim overpayments and subsequent retractions or claim underpayments.

Description

Modifier 53 (discontinued procedure) is reported when a professional provider terminates a surgical or diagnostic procedure due to extenuating circumstances that may threaten the individual's health or well-being.
References

American Medical Association (AMA). CPT Professional Edition: Current Procedural Terminology (Current Procedural Terminology, Professional Ed. (Spiral); 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician practitioners. [CMS Web site]. 07/25/2019. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed September 17, 2019.

2019 Understanding Modifiers (Optum Learning Series) (Optum Learning: Coding & Reimbursement Educational); 2019 Edition.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifiers:

Modifier 53 Discontinued Procedure


Coding and Billing Requirements






Policy History

REVISED FROM MA03.018a
01/13/2020This policy update becomes effective 01/13/2020. This policy has been updated to communicate the Company’s position on Modifier 53 Discontinued Procedure.

REVISED FRO MA03.018
11/21/2018This policy has been reissued in accordance with the Company's annual review process.
10/01/2016This new policy has been developed to communicate the Company's reporting criteria for Modifier 53 Discontinued Procedure.




Version Effective Date: 01/13/2020
Version Issued Date: 01/13/2020
Version Reissued Date: N/A