Modifier 73 Description, Examples, and Usage Guidelines

We understand the frustration when you are all prepped and ready to cure, but due to unforeseen circumstances, you are forced to abort the procedure. But do you know what is more frustrating than that? When insurance payers refuse to reimburse you for all the preliminary work you did for the surgery. In a split second, all your effort goes down the drain because things did not turn out as planned. 

But what if we told you that you can receive compensation equivalent to 50% of the procedure’s cost for your surgical preparations? That’s right! Modifier 73 is here to save the day. Learn all you need to know about this modifier and get rewarded for your readiness. 

Modifier 73 – Description

Modifier 73 is a ‘discontinued procedure’ modifier. It is appended when the healthcare provider has to terminate an outpatient hospital or ambulatory surgery center (ASC) procedure before administering anesthesia, mainly because of the complications or circumstances threatening the patient’s well-being. 

Simply put, it is a last-minute cancelation of the procedure, even though all the surgical preparations are in order, like reserving an operating room, performing pre-surgical tests, getting the staff ready, etc.  

Healthcare providers at outpatient hospitals and ASCs can append modifier 73 with the appropriate CPT code for the intended surgery or procedure to collect 50% of the allowed amount. Insurance payers reimburse providers at half the cost, even though the procedure was not performed, to compensate for the preliminary or preparatory work done for the surgery. 

The Centers for Medicare and Medicaid Services (CMS) and all commercial payers recognize modifier 73 and recommend its usage to denote a discontinued procedure for accurate reimbursement. 

Modifier 73 – Examples

So, now that you know what the medical modifier 73 indicates, here are a couple of real-world examples where this modifier is perfectly applicable.

Open Inguinal Hernia Repair Surgery Termination

Consider a middle-aged man (between the ages of 40 and 60) who was diagnosed with an inguinal hernia (i.e., the intestinal tissue started to protrude through a weak spot in the abdominal muscles) and was advised an open initial inguinal hernia repair surgery for treatment. As it was a minor surgical procedure, the patient was told that the procedure would be performed in an outpatient hospital without an overnight stay. 

A general surgeon and his team performed all the preliminary work for the surgery, such as preparing the operating room, arranging the equipment, and calling an anesthesiologist. However, as soon as the patient was taken to the operating room for general anesthesia administration before the surgery, his blood pressure spiked, making the procedure life-threatening. The surgeon in charge decided to terminate the surgery and postpone it until the patient’s condition became stable. 

In this case, the general surgeon will bill the open inguinal hernia repair surgery with the CPT code 49520 and add modifier 73 to indicate the discontinuation of the procedure before anesthesia administration due to a medical complication.  

Discontinued Pelvic Fracture Surgery During Pregnancy

Assume that a woman in her first trimester of pregnancy fell and injured her hip bone. Her primary care physician examined her and referred her to an ambulatory surgery center for pelvic fracture surgery. The orthopedic surgeon and his team made all the preparations for the surgery but, because of miscommunication, failed to acknowledge that the patient was 12 weeks pregnant and had a history of two miscarriages. 

As they were about to administer anesthesia, the patient asked if the particular dose of anesthetics would be harmful to her fetus. This question prompted a discussion, disclosing the patient’s medical history. It was decided that the pelvic fracture surgery should be discontinued for the time being as anesthesia and the site of the surgery would increase the risk of miscarriage. 

So, while creating the claim for closed treatment of a pelvic ring fracture, the orthopedic surgeon will append modifier 73 with the CPT code 27198 to collect payment for the surgical preparations. 

Accurate Usage Guidelines for Modifier 73 

You must learn the appropriate situations and the correct manner to append the medical modifiers if you want your claim to be processed and your reimbursements to arrive on time without further deductions. To help you, we will list some dos and don’ts for the accurate usage of modifier 73, as suggested by the CMS and commercial insurance payers. Take a look!

Ensure All the Prerequisites Are Met

First and foremost, you must ascertain the fulfillment of all the prerequisites for appending modifier 73. For example, while coding, you must confirm if the planned procedure was supposed to be performed at an outpatient hospital or ambulatory surgery center. 

Second, you must confirm if all the necessary preparations for the surgery were made, such as booking the operating room, performing pre-surgery tests, arranging the drugs and supplies needed for the surgery, etc. 

Third, you should ask the attending staff if the patient was taken to the operating room and the procedure was canceled before sedation due to extenuating circumstances or a threat to the patient’s well-being. Checking all these boxes will put you in the right direction for selecting modifier 73. 

Append in First Pricing Position 

Modifier 73 is a pricing modifier and directly affects the calculated reimbursement amount. The reimbursement is 50% of the actual cost of service. Therefore, as per the rule, it should always be appended before a payment and/or location modifier. So, on the same claim line, your entry should appear like this: XXXXX-73 (where X denotes a single digit of a CPT code). 

Append on Physician Claims, Not Facility Claims 

Do not append modifier 73 on claims filed by the outpatient hospital or ambulatory surgery center. Instead, report it on claims filed for physician services. For example, you cannot use modifier 73 if you are filing an insurance claim for hospital services rendered to the patient, such as hospital bed, drugs and equipment, or wheelchair service. Use it only on the claim that the surgeon will file for the planned but discontinued surgical procedure. 

Reduce the Billed Amount to 50% of the Service Fee

CMS’s system does not automatically calculate and reduce the reimbursement amount to 50% of the allowed fee for the procedure. Therefore, when submitting claims with modifier 73 to the CMS, you should reduce the billed amount by 50% and quote that figure. For example, if the complete surgery amounted to $2,500, you should bill Medicare or Medicaid $1,250 for the discontinued procedure. 

Do Not Append with E/M or Anesthesia CPT Codes 

You cannot append modifier 73 for terminated evaluation and management (E/M) services or anesthesia administrations. It is only applicable for planned diagnostic and surgical procedures. Therefore, do not append this modifier with E/M or anesthesia CPT codes.  

Do Not Append if Service Termination was Elective 

There is a difference between elective termination and canceling/discontinuing the procedure due to extenuating circumstances or medical complications. An elective termination occurs when the patient does not show up for the surgery, is non-compliant, or changes his mind or when the facility has to reschedule the procedure due to staffing issues, supply shortage, space unavailability, etc. 

However, modifier 73 does not indicate an elective procedure termination. Instead, it explains to the insurance payer that the provider discontinued the service because of the patient’s unstable condition or other complications, such as unexpected equipment failure. 

For Multiple Procedures, Only Append With First Canceled Procedure

You can only use modifier 73 with the CPT code for the first planned procedure if multiple procedures were planned for the same day and all were discontinued before sedating the patient. For example, the provider can only apply modifier 73 for venus thrombectomy and not the subsequent stent placement if a venus thrombectomy and stent placement were planned for the same day but were discontinued.

For CMS, Only Append with Certain Diagnostic and Surgical Procedures Requiring Anesthesia

The CMS accepts modifier 73 only for some specified diagnostic and surgical procedures. Moreover, these procedures must be performed when the patient is sedated. For example, you can use modifier 73 for discontinued general surgeries or diagnostic biopsies that require local, regional, or general anesthesia. 

Provide Complete Documentation for Procedure Termination

Your documentation must support the necessity of service cancelation. For example, your operative report must clearly explain the patient’s condition prior to anesthesia administration and why the procedure was terminated at the physician’s discretion. Complete and accurate documentation will support the modifier 73 usage and help you collect the correct payment.   

Modifier 73 vs 74 – Understanding the Difference

Modifiers 73 and 74 are part of the same group. Both are discontinued procedure modifiers and are appended when a surgical procedure is intended to be performed in an outpatient hospital or ambulatory surgery center but terminated due to medical complications. 

However, modifier 73 is appended when the provider terminates the procedure before administering anesthesia, while modifier 74 explains that the procedure was discontinued after administering anesthesia. In both cases, the reason for procedure termination is extenuating circumstances that jeopardize the patient’s well-being. For example, high blood pressure, equipment failure, or an allergic reaction to the administered drugs would warrant postponing the surgery until the patient’s health becomes stable or the equipment is fixed.  

Moreover, modifiers 73 and 74 have distinct effects on the reimbursement rate. Providers only get half the amount quoted in the physician fee schedule for modifier 73, whereas modifier 74 results in full reimbursement.

The key differences between modifiers 73 and 74 are summarized in the table below:

Modifier 73	Modifier 74
The procedure was discontinued before anesthesia administration.	The procedure was discontinued after the administration of planned anesthesia.
The provider receives reimbursement at 50% of the allowed amount.	The provider receives reimbursement at 100% of the allowed amount.

Modifier 73 vs 53 – Understanding the Difference

You must know that four medical modifiers should be considered for discontinued procedures or reduced services. So, modifiers 52, 53, 73, and 74 are part of the same cohort and explain procedure termination or reduction at the surgeon’s discretion. 

While all these modifiers explain service termination or reduction in an ambulatory surgery center or outpatient hospital, at the core, they are distinct and appended to report different situations. Specifically speaking, modifier 53 is appended if the provider had prepped the operating room, administered anesthesia, and initiated the procedure but had to stop midway due to extenuating circumstances or a threat to the patient’s well-being.

In contrast, modifier 73 clarifies that the procedure was discontinued even before the anesthesia was administered due to medical complications, although all the other preparations for the surgery were in order.   

Also, modifiers 73 and 53 have distinct effects on the reimbursement rate, as summarized in the table below:

Modifier 73	Modifier 53
The procedure was discontinued before anesthesia administration.	The procedure was started but was discontinued due to extenuating circumstances.
The provider receives reimbursement at 50% of the allowed amount.	The provider receives reimbursement between 25% and 50% of the allowed amount, depending on the RVU/pricing.

Summary

In this complete guide on modifier 73, we tried to cover all the information that we deemed necessary for the appropriate usage of this modifier. We started our discussion by defining modifier 73 and proceeded to some real-life examples where this modifier is applicable. 

Next, we discussed guidelines for the appropriate usage of the 73 modifier, such as not using it if the surgery was performed in an inpatient setting and ensuring that the procedure termination was not elective. 

After covering the dos and don’ts of modifier 73 usage, we tried to clear the confusion between modifiers 73 and 74 and 73 and 53, as all are discontinued procedure modifiers. We hope that with a clear understanding of this modifier, you will use it when needed to prevent denials.