How do you report a discontinued procedure? With modifier 53! Modifiers are essential for reporting unusual and unique circumstances to payers. A common misconception about these two-digit codes? You can use them randomly to increase reimbursements. In reality, they have specific criteria and only deliver additional details about a service or procedure.
Unforeseen circumstances or life-threatening situations may force you to terminate a surgical or diagnostic procedure. But did you know that you can still receive partial payments for these services with modifier 53? Stay with us to learn everything about this modifier, from its proper use to practical examples and expert guidelines.
Modifier 53 – Description
How many times have you received reimbursements for partially performed services? Modifier 53 can fill your revenue gaps. This two-digit code specifically reports discontinued services.
In simple words, you can use this modifier with CPT codes for procedures that were started but were abandoned by healthcare providers due to extenuating circumstances, such as:
- Adverse reaction to a medication
- Excessive bleeding
- Unstable vital signs
- Difficulty in breathing
In short, any situation that puts a patient’s health at significant risk after the administration of anesthesia may qualify as a reason for termination. Keep in mind that modifier 53 is not applicable when procedures are canceled electively.
Modifier 53 – Examples
Let’s look at some appropriate examples of this modifier.
Discontinued Colonoscopy
Let’s assume a gastroenterologist planned a colonoscopy to investigate a patient’s weight loss and rectal bleeding. He started the procedure but had to stop in the middle due to the patient’s irregular heartbeat and inadequate bowel preparation.
Ultimately, he abandoned the entire procedure due to these extenuating circumstances. The provider used modifier 53 with colonoscopy CPT code 45378 to receive partial payment.
Discontinued IUD Insertion
A 29-year-old woman visits an OB-GYN for an Intrauterine Device (IUD) placement. The doctor prepares the patient and places a sound into the endometrial cavity. However, she fails to insert the IUD due to anatomical issues, such as a narrow endocervical canal or uterine fibroids, and discontinues the procedure.
The billing team files a claim for this discontinued procedure (CPT code 58300) with modifier 53 to receive payment for surgical preparation and anesthesia induction. Remember that this is just a scenario, and Medicare does not cover IUD insertions.
Failed Esophagogastroduodenoscopy (EGD)
Let us give you one more example! A doctor prepares to examine the patient’s esophagus lining, stomach, and first part of the intestine. To help them relax, the doctor administers a sedative and sprays local anesthesia into their mouth to reduce gagging and discomfort.
The situation becomes critical when the doctor tries to insert an endoscope into the patient’s stomach via his esophagus. The patient experiences unexpected hypoxemia (low oxygen level in the blood). As a result, the doctor immediately stops the procedure and provides a life-saving intervention.
Since the situation was unusual, the billing team used modifier 53 with CPT code 43235 to claim reimbursement for EGD preparation and anesthesia.
Accurate Usage Guidelines for Modifier 53
We have tried to clear some of your confusion with the examples above. However, to avoid claim denials, you should also be familiar with the appropriate and inappropriate usage of modifier 53.
Appropriate Usage
You should only use this modifier when a qualified doctor has to discontinue a procedure due to unforeseen circumstances. In simple words, there should be a valid reason for discontinuation.
Moreover, you should clearly document these circumstances to communicate the medical necessity behind your decision. Your records should also specify how much of the procedure was completed.
In short, modifier 53 is only applicable when a procedure is discontinued due to the following reasons:
- Unexpected medical conditions
- Patient safety concerns (stroke, hypoxemia, or other life-threatening conditions)
- Anatomical issues, obstruction, or technical difficulties.
- After anesthesia administration
Keep in mind that this modifier only addresses discontinued physician or professional services. Moreover, you can only append it with one procedural code per date of service.
Inappropriate Usage
You should never use this modifier in the following circumstances:
- When the discontinuation of a procedure is voluntary (primarily due to non-medical reasons)
- When a procedure is terminated before anesthesia induction
- When there is a temporary interruption
Modifier 53 also does not apply to the following procedures or codes:
- Multi-staged planned procedures
- E/M service codes
- Ambulatory Surgery Center (ASC) or outpatient services.
- Time-based procedural codes (critical care, psychotherapy, and anesthesia)
Modifier 53 vs 52 – Understanding the Difference
Are you confused between modifiers 53 and 52? You might not be the only one, as both highlight a partially performed procedure and result in reduced payments. Many physicians and practices face unexpected claim denials due to this confusion. However, modifier 53 is quite different from modifier 52. Let’s understand their key differences:
Descriptions
As mentioned above, modifier 53 refers to discontinued procedures. On the other hand, modifier 52 specifies reduced services. So, what is the difference between reduced and discontinued services? Discontinued procedures are usually those that were started by healthcare providers but were stopped and discontinued due to a medical necessity.
Meanwhile, reduced procedures are those procedures that were performed but were slightly less extensive than planned at the physician’s discretion. It means they had fewer steps than usually required.
Reasons for Discontinuing/Reducing Services
Billing teams use modifier 53 when there is a critical reason for discontinuing a procedure. These include extenuating circumstances (unexpected events beyond anyone’s control), like equipment failure or unforeseen deterioration of a patient’s condition.
On the other hand, billing experts use modifier 52 when a doctor reduces a procedure based on his judgment or due to time limitations.
Anesthesia Induction
The use of anesthesia is another key difference between modifiers 52 and 53. You can only apply modifier 53 after anesthesia administration. It simply means that this modifier is only applicable when a provider terminates a procedure after administering anesthesia.
In contrast, modifier 52 typically specifies those reduced services that do not require anesthesia. Simply put, it is primarily used with radiology procedural codes.
Summary
In conclusion, modifier 53 is ideal for reporting discontinued diagnostic or surgical procedures. However, you cannot use it with every service, especially ASC or outpatient services. Want to know the most interesting part? It is often referred to as a forgotten modifier because many practices simply never use it.
But why miss out on revenue opportunities? If you want to claim payments for every effort, it is important to familiarize yourself with this two-digit code. We have covered modifier 53 in detail to help you secure partial payments for discontinued services.
