Description:
This policy provides guidelines for the reimbursement of services with modifiers 73 and 74 for professional provider.
Definitions:
Modifier
|
Description |
| 73 |
Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia |
| 74 |
Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia |
Policy:
The modifiers 73 and 74 can only be used when the procedure is provided by an outpatient hospitals or 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 of a discontinued procedure, refer to Modifiers 52 & 53 Reimbursement Policy.
Modifier
|
Reimbursement Percentage
|
73
|
50% of the fee schedule |
| 74 |
100% of the fee schedule |
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.
Cross Reference:
Modifiers 52 & 53
History:
Date
|
Updates
|
| 10/03/19 |
Added Limitations and Exclusions, Disclaimer and History. |
