Modifier 53 is used on CPT codes to reflect services that have been terminated. That implies that it should be used to CPTs that indicate diagnostic treatments or surgical services that the practitioner has completed. Modifier 53 is only applicable to professional physician services and does not relevant to ASC treatments. The operation is typically stopped due to unexpected extraordinary factors that might threaten the patient’s well-being if the treatment were to be done.
Now, modification 53 is similar to modifier 52 for reduced services, but please keep in mind that the two are very different in terms of how they should be utilized correctly.
These modifiers can be confusing, and if used wrong, they can result in underpayment or even rejection. We’ll examine and clarify modification 52 in a later post in this sequence, but for now, let’s look at modifier 53 and when it might apply.
Why is modifier 53 important?
Modifier 53 is almost neglected; practitioners either forget or never understand how to utilize it correctly. There is no standard definition for ‘mitigating circumstances,’ leaving it up to opinion and limiting its proper usage. Unfortunately, modifier 53 is so underutilized because by not employing it, practitioners miss out on half remuneration for work done by being compensated for travel expenses. When a process is stopped, using modifier 53 assures that the provider will be able to ultimately bill that same treatment later, when it can be conducted in its entirety.
MODIFIER 53: Discontinued procedures
According to CPT Appendix A, “it may be essential to mention that a surgical or diagnostic treatment was started but discontinued due to mitigating factors or those that risk the patient’s well-being.” This scenario can be recorded by appending modifier 53 to the code for the stopped procedure recorded by the physician. Modifier 53 may also apply if the provider is forced to stop treatment due to equipment malfunction or other unforeseen reasons. This modification is used to describe services or procedures that are ceased once the patient has been given anesthesia.
• Circumstances that are unusual (discontinued).
• An operation that was halted after anesthetic was administered.
• Add a modification to the CPT code of the terminated procedure.
• To notify the operating room of an elective abandonment of surgery before the patient’s anesthetic induction and surgical preparation.
• When applied to E/M services
• In the case of an outpatient hospital or an ambulatory surgery center
• To notify an elective treatment cancellation before the patient’s anesthetic induction and surgery preparations in the operating room.
• Modifier 53 is only usable on a single procedure code per service date. When several procedures were planned:
• Modifier 53 is applied to the first planned procedure when none of the planned operations is accomplished. The second intended procedure(s) are not mentioned.
• Modifiers 50 and 53 may not be submitted simultaneously on the exact procedure code.
• Only a unilateral procedure code may be submitted with modifier 53 when a bilateral surgery is scheduled and terminated before either side is finished.
• If one or both of the planned operations is performed, the completed procedures are reported in the usual manner. Other treatments that are stopped or do not finish are not recorded and are not qualified for separate reimbursement.
• The medical record must include information indicating the procedure was started, why it was stopped, and what proportion of the therapy was completed. These proper documents must be made available upon demand.
• Paperwork supporting the process should: state when the process was initiated; and describe why the procedure was ended.
• Make a note of the percentage of the process that was completed.
• Additional details to support the modification can be included in the claim story. Documentation must be provided if data cannot be presented in the narrative.
We hope that this article has provided you with all of the knowledge you need to use modifier 53 correctly. If you are still unsure and require assistance with medical billing for your clinic, please contact us. We have more than 10 years of experience in US medical billing, allowing you to generate revenue quickly without worrying about claims denials. We assist you in streamlining your billing processes and mitigating the associated concerns.
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