New Reimbursement Rules for Modifier 53

Date Issued: 10/8/2015

Modifier 53 reimbursement

Effective September 1, 2015, reimbursement under all plans will be 50% of the base fee schedule. This does not include multiple surgical reduction, bilateral pricing, etc., that may also be applied.

Modifier 53 – Discontinued procedure

This modifier must be submitted in the first modifier field.

Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. It may be necessary to indicate that a surgical or diagnostic procedure was started, but discontinued due to extenuating circumstances or conditions that threaten the well-being of the patient. This circumstance must be reported by adding CPT modifier 53 to the code reported by the physician for the discontinued procedure.

Incorrect use of modifier 53:

  • Do not use modifier 53 for an elective cancellation of the procedure.
  • Do not use to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite.
  • Do not use on an Evaluation and Management Procedure Code.
  • Do not use on time-based procedure codes. (i.e., critical care and psychotherapy).
  • Do not submit CPT modifier 53 when a laparoscopic or endoscopic procedure is converted to an open procedure.

Appropriate use modifier 53:

  • This modifier can be used with both diagnostic and surgical CPT codes.
  • Bill modifier 53 with the CPT code for the service furnished.
  • This modifier is used to report a service or procedure when the service or procedure is discontinued after anesthesia is administered to the patient.

Facilities reporting a discontinued outpatient procedure should use modifier 73 or 74.

Supporting documentation should:

  • be available upon request.
  • state the procedure was started.
  • explain why the procedure was discontinued.
  • state the percentage of the procedure that was performed.
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