Preoperative Period
An E/M visit rendered during the preoperative period is included in the global surgery allowance for the surgery and not separately reimbursable. However, reimbursement may be made for a significant, separately identifiable E/M service by the same physician on the same day when modifier 25 or FT is reported with the E/M code. When the 25 or FT modifier is reported, the medical records must clearly document separately identifiable medical care was rendered. Modifier 25 or FT should only be used on claims for E/M services, and only when these services are provided by the same physician or QHP to the same patient on the same day as another procedure or other service.
Decision for Surgery
E/M services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery. Therefore, the E/M may be billed with the 57 modifier appended and will be reviewed for separate reimbursement.
Intraoperative Period
Reduced & Discontinued Services
Reduced Services
In situations where the physician or other QHP has elected to partially reduce or eliminate the procedure the modifier 52 is appended to the procedure code, signifying that the physician did not perform the complete procedure in the code descriptor.
Discontinued Services
Professional Claims
Discontinuation of a procedure is usually the result of extenuating circumstances or those that threaten the well-being of the patient. When the surgeon elects to terminate a surgical or diagnostic procedure due to extenuating circumstances or those that threaten the well-being of the patient modifier 53 is appended.
Note: Modifier 53 may only be billed on the CMS-1500 Claim Form.
Outpatient Hospital & Ambulatory Surgical Center (ASC)
In the instance where a planned service or procedure in the hospital outpatient setting is reduced, cancelled, or discontinued and anesthesia is planned but not administered, modifier 73 would be appended to the procedure code; and if anesthesia is administered then append modifier 74.
Note: Modifiers 73 and 74 may only be billed on the UB-04 Claim Form.
Discontinued Procedure Prior to Anesthesia
A physician or other QHP may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general).
Discontinued Procedure After Administered Anesthesia
A physician or other QHP cancels the procedure due to extenuating circumstance or those that threaten the well-being of the patient after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.).
Note: Do not report modifiers 73 or 74 when a radiology procedure does not require anesthesia or the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient.
Reimbursement for Reduced & Discontinued Services
Under Enhanced Ambulatory Patient Groups (EAPGs) pricing methodology, modifier 52 or 73 can also be used on the UB-04 Claim Form to indicate a discontinued outpatient hospital/ASC procedure prior to the administration of anesthesia.
Reduced & Discontinued Services Modifiers, Reimbursement Percentage & Claim Form
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52
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Reduced Services
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50% of the fee schedule
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CMS-1500 & UB-04
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53
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Discontinued Procedure
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50% of the fee schedule
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CMS-1500
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73
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Discontinued Outpatient Hospital/ASC Procedure Prior to the Administration of Anesthesia
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50% of the fee schedule
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CMS-1500 & UB-04
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74
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Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia
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100% of the fee schedule
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UB-04
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