Sunday, May 30, 2010

Modifier 53 - Discontinued Procedure

Part - A  Level I Modifiers - 53

Description Discontinued Procedure

Required for Claims Critical Access Hospitals (CAHs) Electing the Optional Payment Method (Method II) Type of Bill: 85X

Coding Guidelines -53 modifier should be applied to revenue codes 0963, 096X, 097X or 098X for discontinued services (e.g. cancelled colonoscopy)

General Guidelines

• Modifier -53 is used to indicate discontinuation of physician services and is not approved for use for outpatient hospital services.

• When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for  the incomplete procedure.

• The policy applies to both screening and diagnostic colonoscopies.



Reimbursement Guidelines

Modifier 53 is considered valid on a maximum of one procedure code per date of service. When multiple procedures were planned:

• It is never appropriate to report more than one procedure code with modifier 53.

• When none of the planned procedures is completed, then the first planned procedure is reported with modifier 53. The other planned procedure(s) are not reported.

• If one or more of the procedures planned is completed, the completed procedures are reported as usual. The other procedure(s) that are discontinued or not completed are not reported and are not eligible for separate reimbursement.


Exceptions:

o Upper GI and Lower GI procedures, same day:

The only time it is appropriate to report a discontinued procedure with modifier 53 in combination with completed procedure codes is when the completed procedures are upper GI endoscopy procedures and the single, discontinued procedure is a lower GI endoscopy, or vice versa. However, it is still not appropriate to report a completed lower GI procedure code in combination with a discontinued lower GI procedure code. In that case, only the completed lower GI code may be reported.


Correct usage and non usage Tips


Under certain circumstances such as a serious risk to the patient's well-being, a surgical or diagnostic procedure is terminated at the physician, hospital, ambulatory surgical center or other health care professional's direction. Under these circumstances the procedure provided should be identified by its usual procedure code and the addition of Modifier 53 (Discontinued Procedure) signifying that the procedure was started but discontinued. This provides a means of reporting the Discontinued Procedure leaving the identification of the basic service intact.

According to the Centers for Medicare & Medicaid Services (CMS) and CPT coding guidelines, modifier 53 should be used with surgical codes or medical diagnostic codes. Modifier 53 should not be used with:

** Evaluation and management (E/M) services

** Elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite

** When a laparoscopic or endoscopic procedure is converted to an open procedure or when a procedure is changed or converted to a more extensive procedure.

Oxford’s standard for reimbursement of Discontinued Procedures with modifier 53 is 25% of the Allowable Amount for the primary unmodified procedure. Multiple procedure reductions will still apply. For procedures that are partially reduced or eliminated at the physician's direction, see the Reduced Services Policy (Modifier 52).


Billing Guidelines

Effective for services performed on or after January 1, 2016, the Medicare Physician Fee Schedule (MPFS) database will have specific values for Current Procedural Terminology (CPT) codes 44388-53; 45378-53; G0105-53; and G0121-53.


Incomplete colonoscopies are reported with Modifier 53. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the  codes.



According to CPT instruction, prior to calendar year (CY) 2015, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). Physicians were previously instructed to report an  incomplete colonoscopy with 45378 and append Modifier 53 (discontinued procedure), which is paid at the same rate as a sigmoidoscopy.

In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states:

“When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.”

Therefore, in accordance with the change in CPT Manual language, the Centers for Medicare and Medicaid Services (CMS) has applied specified values in the Medicare Physician Fee Schedule (MPFS) database for the following codes:

** 44388-53 (colonoscopy through stoma);

** 45378-53 (colonoscopy);

** G0105-53 (colorectal cancer screening; colonoscopy on individual at high risk; and

** G0121-53 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).



Effective for services performed on or after January 1, 2016, the MPFS database will have specific values for the codes listed above. Given that the new CPT definition of an incomplete colonoscopy also include colonoscopies where the colonoscope is advanced past the splenic flexure but not to the cecum, CMS has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016. Incomplete colonoscopies are reported with Modifier 53. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.


Codes and Definitions Modifier 53

Discontinued Procedure: Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure.

Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.

For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use.)




Coding Guidelines

CPT Modifier 53 was created in 1997 to distinguish between procedures which are reduced at the physician’s discretion and procedures which are stopped mid-stream because the patient experienced a life-threatening condition.

• Procedures which are reduced at the physician’s discretion are reported with modifier 52.

• Procedures which are terminated or discontinued due to a patient's life-threatening condition are reported with modifier 53. CPT Assistant, December 1996 states:

“CPT Modifier -53 should be appended to a procedure code to report those circumstances when a patient experiences an unexpected response, (eg, arrhythmia or hypotensive/hypertensive crisis) causing the procedure to be terminated. This modifier differs from CPT modifier -52 (which describes a procedure that was reduced at the physician' discretion) because the patient's life-threatening condition precipitates the terminated procedure.”

Appropriate Use

Modifier 53 may be used with surgical or diagnostic procedures and reported by physicians or other qualified health care professionals.

Modifier 53 may not be reported by facilities.


Inappropriate Use

• Reporting more than one procedure code with modifier 53 attached.

• To report elective cancelation of a procedure.

• To report cancellation prior to anesthesia induction and/or surgical preparation in the operating suite.

• To report a laparoscopic procedure which is subsequently converted to an open procedure.

• When appended to Evaluation and Management procedure codes.

• May not be appended to time-based procedure codes (e.g. critical care, psychotherapy, therapeutic procedures)


DESCRIPTION:

The term discontinued procedure designates a surgical or diagnostic procedure provided by a physician or other health care professional that was less than usually required for the procedure as defined in the Current Procedural Terminology (CPT®) book. Discontinued procedures are reported by appending modifier 53.

Modifier 53 is used when a procedure was actually started, but was discontinued before completion due to extenuating circumstances or those that threaten the well-being of the patient.



REIMBURSEMENT INFORMATION:

Reimbursement of discontinued procedures with Modifier 53 is 50% of the allowable amount for the primary unmodified procedure. Multiple procedure reductions may also apply.

If based on post payment clinical records review, Modifier 53 was not reported when indicated, Florida Blue will apply appropriate edit and adjust payment consistent with this policy.

Exception: For procedure codes 44388, 45378, G0105, & G0121, CMS publishes relative values (RVUs) for modifier 53. Therefore, the allowance for these procedures will be based on the RVU rate via the fee schedule and an additional 50% reduction is not applied.

Modifier 53 is not used to report the elective cancellation of a procedure, prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.
For procedures that are partially reduced or eliminated at the physician’s direction, see the Reduced Services Policy describing the use of modifier 52.


BILLING AND CODING:

According to the Centers for Medicare and Medicaid Services (CMS) and CPT coding guidelines, modifier 53 should be used with surgical codes or medical diagnostic codes.



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