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 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.
- 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.
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.