Description:
This policy provides guidelines for the reimbursement of services with modifiers 52, 53, 73 and 74.
Definitions:
Modifier
|
Description
|
Claim Type
|
Reimbursement Percentages
|
52
|
Reduced Services
|
CMS-1500 & UB-04
|
50% of the fee schedule
|
53
|
Discontinued Procedure
|
CMS-1500
|
50% of the fee schedule
|
73
|
Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia
|
CMS-1500 & UB-04
|
50% of the fee schedule
|
74
|
Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia
|
UB-04
|
100% of the fee schedule
|
Note: Effective October 1, 2019 modifier 52 will be reimbursed at 50% of the fee schedule. Any claims with a date of service prior to October 1, 2019 will be reimbursed at 80% of the fee schedule
Policy:
Modifier 52 - Reduced Services is used to report a service or procedure that is performed at a reduced level from what is specified by the code descriptor. When a physician or qualified health care professional (QHP) does not complete a procedure in its entirety or elects to partially reduce or discontinue the procedure for reasons other than the patient’s health being threatened, the procedure must be billed by appending modifier 52.
When a physician or QHP decides to terminate a procedure due to extenuating circumstances, such as if the well-being of the patient is threatened, making it necessary to indicate that the surgical or diagnostic procedure was started but discontinued. This circumstance must be reported by appending modifier 53 to indicate the procedure was discontinued.
Do not use modifier 52 or 53 with time-based or Evaluation and Management (E&M) codes.
The modifiers 73 and 74 can only be used when the procedure is provided by an outpatient hospital or Ambulatory Surgical Center (ASC).
Discontinuation of a procedure is usually the result of extenuating circumstances or those that threaten the well-being of the patient. A physician 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). Under these circumstances, the intended service that is prepared for but canceled can be reported with the appropriate code and modifier 73.
When the physician 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.), report with the appropriate code and modifier 74.
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. For physician reporting on the CMS-1500 Claim Form of a discontinued procedure, refer to Modifier 53.
Note: 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.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
History:
Date
|
Updates
|
11/25/2020
|
Combined policies for Modifiers 52 and 53 and Modifiers 73 and 74. Noted that with EAPG pricing methodology modifier 52 or 73 can be used on the UB-04 Claim Form to indicate a discontinued outpatient hospital/ASC procedure prior to the administration of anesthesia.
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