CPT Modifier 53

Description
Discontinued procedure

Note: Ambulatory Surgical Centers (ASCs) may not submit CPT modifier 53.

Guidelines/Instructions
Submit CPT modifier 53 with surgical codes or medical diagnostic codes when the procedure is discontinued because of extenuating circumstances.

  • Use to report services or procedure when the services or procedure is discontinued after anesthesia is administered to the patient
  • Do not submit CPT modifier 53 to report an elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. No payment is issued for a procedure when it is an elected cancellation prior to anesthesia induction and/or surgical preparation in the operating suite.
  • Do not submit CPT modifier 53 when a laparoscopic or endoscopic procedure is converted to an open procedure

When appropriate, add CPT modifier 53 to the code reported by the physician or practitioner for the discontinued procedure. Additional actions are also required when this modifier is used.

  • This modifier must be submitted in the first modifier field  
  • Documentation required with the claim:
    • A concise statement that explains why it was medically necessary to discontinue the procedure and the length/amount of procedure completed along with any other supporting documentation that the provider deems relevant (i.e., operative report).
      • Example: Colonoscopy terminated due to poor prep; unable to insert past splenic flexure 
      • Note: payment for discontinued procedures is based on the percentage of service completed
    • This statement may be entered in the electronic documentation field or submitted as an attachment
  • For paper claims:
    • There must be sufficient comment/notation to determine how much of the procedure was done prior to termination. For example: “pt c/o dizziness, procedure terminated, stopped procedure, incomplete procedure, reduced service etc.” is not sufficient. The reviewer must be able to clearly determine that the procedure was started, how much of the procedure was completed and why the procedure was terminated to appropriately price the procedure.
    • Services that are submitted with CPT modifier 53 that do not include a concise statement will be rejected as “unprocessable” with remark MA130 and must be corrected and resubmitted as new claims

Note: When an outpatient hospital or ASC is reporting a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia; see CPT modifiers 73 and 74.

References

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