MA PPO

Modifier 53 Discontinued Procedure
MA03.018a


Policy

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.

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

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

Modifiers

Modifier 53 Discontinued Procedure

Coding and Billing Requirements



Policy History

1/13/2020
1/13/2020
MA03.018
Claim Payment Policy Bulletin
Medicare Advantage
Yes