Commercial

Medical Policy

Notification

Modifier 53: Discontinued Procedure

Notification Issue Date:

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

Title:

Modifier 53: Discontinued Procedure

Policy #:

03.00.33b

Policy

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 policy applies to professional and outpatient facility claims.

Modifier 53, used to indicate that a procedure or service (e.g. surgical or diagnostic) was discontinued due to extenuating circumstances that may threaten the individual's well-being, is eligible for reimbursement consideration by the Company.

It is inappropriate to append Modifier 53 in the following circumstances:

When used to report any of the following types of services:
- Psychotherapy services
- Evaluation and Management (E & M) services
- Anesthesia services
The elective cancellation of a procedure before administering anesthesia and/or prior to surgical preparation in the operating room
A discontinued surgical or diagnostic procedure in an outpatient hospital or ambulatory surgical center (ASC). In this case it is more appropriate to report one of the following modifiers;

Modifier 73: Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia
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 such cases, Modifier 52 (reduced services) is more appropriate to be reported.
To report a laparoscopic or endoscopic procedure that is converted to an open procedure. In such cases only the open procedure should be reported.

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

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. Claims submitted with modifier 53 are subject to pre- and post-payment review and potential denials or retractions for inappropriate use.

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).

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

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

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 21, 2021.

Novitas Solutions, Inc. Modifier 53 Fact Sheet. 10/28/2019. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00154901.

Accessed September 21, 2021.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

53 Discontinued Procedure

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 03.00.33b:

09/06/2023

This policy has been reissued in accordance with the Company's annual review process.

12/06/2021

This version of the policy will become effective 12/06/2021. The intent of this policy remains unchanged, but the policy has been updated to clarify the company's coverage and reporting criteria for Modifier 53.

Revisions From 03.00.33a:

01/13/2020

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

Revisions From 03.00.33:

11/21/2018

This policy has been reissued in accordance with the Company's annual review process.

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date:

12/6/2021

Version Issued Date:

12/5/2021

Version Reissued Date:

9/6/2023