Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifier 53 Discontinued Procedure

Policy #:03.00.33a


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

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

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 December 12, 2019.

Novitas Solutions, Inc. Modifier 53 Fact Sheet. 10/28/2019. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00154901. Accessed December 12, 2019.



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 03.00.33a
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 FROM 03.00.33
11/21/2018This 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: 01/13/2020
Version Issued Date: 01/13/2020
Version Reissued Date: N/A



2017 AmeriHealth.